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de Lima AV, de Oliveira Lima K, da Costa Rocha DA, Cappellano P, Boszczowski Í, Sampaio SCF, Sampaio JLM. Performance of two immunochromatographic tests in detecting KPC variants conferring resistance to ceftazidime-avibactam. Eur J Clin Microbiol Infect Dis 2024; 43:1251-1253. [PMID: 38619764 DOI: 10.1007/s10096-024-04815-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 03/19/2024] [Indexed: 04/16/2024]
Affiliation(s)
- Aline Valério de Lima
- Faculdade de Ciências Farmacêuticas, Laboratório RAMC - Resistência Antimicrobiana e Microbiologia Clínica, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Keila de Oliveira Lima
- Faculdade de Ciências Farmacêuticas, Laboratório RAMC - Resistência Antimicrobiana e Microbiologia Clínica, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | | | | | | | | | - Jorge Luiz Mello Sampaio
- Faculdade de Ciências Farmacêuticas, Laboratório RAMC - Resistência Antimicrobiana e Microbiologia Clínica, Universidade de São Paulo (USP), São Paulo, SP, Brazil.
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Han Y, Zhang Y, Zhang X, Huang Z, Kong J, Wang X, Chen L, Wang Y, Cao J, Zhou T, Shen M. PAM-1: an antimicrobial peptide with promise against ceftazidime-avibactam resistant Escherichia coli infection. Front Microbiol 2024; 15:1291876. [PMID: 38765679 PMCID: PMC11099939 DOI: 10.3389/fmicb.2024.1291876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
Introduction Antibiotic misuse and overuse have led to the emergence of carbapenem-resistant bacteria. The global spread of resistance to the novel antibiotic combination ceftazidime-avibactam (CZA) is becoming a severe problem. Antimicrobial peptide PAM-1 offers a novel approach for treating infections caused by antibiotic-resistant bacteria. This study explores its antibacterial and anti-biofilm activities and mechanisms against CZA-resistant Escherichia. Coli (E. coli), evaluating its stability and biosafety as well. Methods The broth microdilution method, growth curve analysis, crystal violet staining, scanning electron microscopy, and propidium iodide staining/N-phenyl-1-naphthylamine uptake experiments were performed to explore the antibacterial action and potential mechanism of PAM-1 against CZA-resistant E. coli. The biosafety in diverse environments of PAM-1 was evaluated by red blood cell hemolysis, and cytotoxicity tests. Its stability was further assessed under different temperatures, serum concentrations, and ionic conditions using the broth microdilution method to determine its minimum inhibitory concentration (MIC). Galleria mellonella infection model and RT-qPCR were used to investigate the in vivo antibacterial and anti-inflammatory effects. Results and discussion In vitro antibacterial experiments demonstrated that the MICs of PAM-1 ranged from 2 to 8 μg/mL, with its effectiveness sustained for a duration of 24 h. PAM-1 exhibited significant antibiofilm activities against CZA-resistant E. coli (p < 0.05). Furthermore, Membrane permeability test revealed that PAM-1 may exert its antibacterial effect by disrupting membrane integrity by forming transmembrane pores (p < 0.05). Red blood cell hemolysis and cytotoxicity tests revealed that PAM-1 exerts no adverse effects at experimental concentrations (p < 0.05). Moreover, stability tests revealed its effectiveness in serum and at room temperature. The Galleria mellonella infection model revealed that PAM-1 can significantly improve the survival rate of Galleria mellonella (>50%)for in vivo treatment. Lastly, RT-qPCR revealed that PAM-1 downregulates the expression of inflammatory cytokines (p < 0.05). Overall, our study findings highlight the potential of PAM-1 as a therapeutic agent for CZA-resistant E. coli infections, offering new avenues for research and alternative antimicrobial therapy strategies.
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Affiliation(s)
- Yijia Han
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Yi Zhang
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Xiaodong Zhang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zeyu Huang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jingchun Kong
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Xiuxiu Wang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Lijiang Chen
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yue Wang
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Jianming Cao
- School of Laboratory Medicine and Life Science, Wenzhou Medical University, Wenzhou, China
| | - Tieli Zhou
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Mo Shen
- Department of Clinical Laboratory, Key Laboratory of Clinical Laboratory Diagnosis and Translational Research of Zhejiang Province, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Nasrollahian S, Graham JP, Halaji M. A review of the mechanisms that confer antibiotic resistance in pathotypes of E. coli. Front Cell Infect Microbiol 2024; 14:1387497. [PMID: 38638826 PMCID: PMC11024256 DOI: 10.3389/fcimb.2024.1387497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Accepted: 03/15/2024] [Indexed: 04/20/2024] Open
Abstract
The dissemination of antibiotic resistance in Escherichia coli poses a significant threat to public health worldwide. This review provides a comprehensive update on the diverse mechanisms employed by E. coli in developing resistance to antibiotics. We primarily focus on pathotypes of E. coli (e.g., uropathogenic E. coli) and investigate the genetic determinants and molecular pathways that confer resistance, shedding light on both well-characterized and recently discovered mechanisms. The most prevalent mechanism continues to be the acquisition of resistance genes through horizontal gene transfer, facilitated by mobile genetic elements such as plasmids and transposons. We discuss the role of extended-spectrum β-lactamases (ESBLs) and carbapenemases in conferring resistance to β-lactam antibiotics, which remain vital in clinical practice. The review covers the key resistant mechanisms, including: 1) Efflux pumps and porin mutations that mediate resistance to a broad spectrum of antibiotics, including fluoroquinolones and aminoglycosides; 2) adaptive strategies employed by E. coli, including biofilm formation, persister cell formation, and the activation of stress response systems, to withstand antibiotic pressure; and 3) the role of regulatory systems in coordinating resistance mechanisms, providing insights into potential targets for therapeutic interventions. Understanding the intricate network of antibiotic resistance mechanisms in E. coli is crucial for the development of effective strategies to combat this growing public health crisis. By clarifying these mechanisms, we aim to pave the way for the design of innovative therapeutic approaches and the implementation of prudent antibiotic stewardship practices to preserve the efficacy of current antibiotics and ensure a sustainable future for healthcare.
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Affiliation(s)
- Sina Nasrollahian
- Department of Bacteriology and Virology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Jay P. Graham
- Environmental Health Sciences Division, School of Public Health, University of California, Berkeley, CA, United States
| | - Mehrdad Halaji
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Babol, Iran
- Department of Medical Microbiology and Biotechnology, School of Medicine, Babol University of Medical Sciences, Babol, Iran
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Mushtaq S, Vickers A, Woodford N, Livermore DM. Activity of aztreonam/avibactam and ceftazidime/avibactam against Enterobacterales with carbapenemase-independent carbapenem resistance. Int J Antimicrob Agents 2024; 63:107081. [PMID: 38176458 DOI: 10.1016/j.ijantimicag.2023.107081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/01/2023] [Accepted: 12/29/2023] [Indexed: 01/06/2024]
Abstract
Enterobacterales with carbapenemase-independent resistance to carbapenems are sometimes selected during therapy and, on rare occasions, cause outbreaks. Most have extended-spectrum or AmpC β-lactamases, together with changes to permeability or penicillin-binding proteins (PBPs). Newer β-lactam-β-lactamase inhibitor combinations may present useful options for infections due to these organisms. Accordingly, Clinical and Laboratory Standards Institute/European Committee on Antimicrobial Susceptibility Testing broth-microdilution was used to measure the minimum inhibitory concentrations (MICs) of ceftazidime/avibactam and aztreonam/avibactam for 51 carbapenemase-negative Enterobacterales with resistance or reduced susceptibility to carbapenems: genomic sequencing of the least-susceptible organisms was also undertaken. MICs of the two avibactam combinations cross-correlated closely, but with fewer MICs (2/51 vs. 10/51) exceeding 8+4 mg/L in the case of ceftazidime/avibactam. Raised MICs for Escherichia coli were associated with PBP3 inserts together with CMY-42 β-lactamase; correlates among Enterobacter cloacae complex isolates remain elusive, with AmpC and PBP3 sequences found to be species specific. In the case of Klebsiella spp., no MICs exceeding 2 mg/L were seen for either combination. It appears that these avibactam combinations have potential against Enterobacterales with carbapenemase-independent carbapenem resistance or reduced susceptibility, with ceftazidime/avibactam being more reliably active than aztreonam/avibactam.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, UK Health Security Agency, London, UK
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, UK Health Security Agency, London, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, UK Health Security Agency, London, UK
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Mendes Pedro D, Paulo SE, Santos CM, Fonseca AB, Melo Cristino J, Pereira ÁA, Caneiras C. Extensively drug-resistant Pseudomonas aeruginosa: clinical features and treatment with ceftazidime/avibactam and ceftolozane/tazobactam in a tertiary care university hospital center in Portugal - A cross-sectional and retrospective observational study. Front Microbiol 2024; 15:1347521. [PMID: 38414772 PMCID: PMC10896734 DOI: 10.3389/fmicb.2024.1347521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/15/2024] [Indexed: 02/29/2024] Open
Abstract
Introduction Extensively drug-resistant Pseudomonas aeruginosa (XDR-PA) is a growing concern due to its increasing incidence, limited therapeutic options, limited data on the optimal treatment, and high mortality rates. The study aimed to characterize the population, the outcome and the microbiological characteristics of XDR-PA identified in a Portuguese university hospital center. Methods All XDR-PA isolates between January 2019 and December 2021 were identified. XDR-PA was defined as resistance to piperacillin-tazobactam, third and fourth generation cephalosporins, carbapenems, aminoglycosides and fluoroquinolones. A retrospective analysis of the medical records was performed. Results One hundred seventy-eight individual episodes among 130 patients with XDR-PA detection were identified. The most common sources of infection were respiratory (32%) and urinary tracts (30%), although skin and soft tissue infections (18%) and primary bacteremia (14%) were also prevalent. Colonization was admitted in 64 cases. Several patients had risk factors for complicated infections, most notably immunosuppression, structural lung abnormalities, major surgery, hemodialysis or foreign intravascular or urinary devices. XDR-PA identification was more frequent in male patients with an average age of 64.3 ± 17.5 years. One non-susceptibility to colistin was reported. Only 12.4% were susceptible to aztreonam. Ceftazidime-avibactam (CZA) was susceptible in 71.5% of the tested isolates. Ceftolozane-tazobactam (C/T) was susceptible in 77.5% of the tested isolates. Antibiotic regimens with XDR-PA coverage were reserved for patients with declared infection, except to cystic fibrosis. The most frequently administered antibiotics were colistin (41 cases), CZA (39 cases), and C/T (16 cases). When combination therapy was used, CZA plus colistin was preferred. The global mortality rate among infected patients was 35.1%, significantly higher in those with hematologic malignancy (50.0%, p < 0.05), followed by the ones with bacteremia (44.4%, p < 0.05) and those medicated with colistin (39.0%, p < 0.05), especially the ones with respiratory infections (60.0%). Among patients treated with CZA or C/T, the mortality rate seemed to be lower. Discussion XDR-PA infections can be severe and difficult to treat, with a high mortality rate. Even though colistin seems to be a viable option, it is likely less safe and efficient than CZA and C/T. To the best of the authors' knowledge, this is the first description of the clinical infection characteristics and treatment of XDR-PA in Portugal.
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Affiliation(s)
- Diogo Mendes Pedro
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Instituto de Farmacologia e Neurociências, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Laboratório de Microbiologia na Saúde Ambiental, Laboratório Associado TERRA, Instituto de Saúde Ambiental, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Sérgio Eduardo Paulo
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Carla Mimoso Santos
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Clínica Universitária de Doenças Infeciosas, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Ana Bruschy Fonseca
- Serviço de Patologia Clínica, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - José Melo Cristino
- Serviço de Patologia Clínica, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Instituto de Microbiologia, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Álvaro Ayres Pereira
- Serviço de Doenças Infeciosas, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
- Unidade Local do Programa de Prevenção e Controlo de Infeções e das Resistências aos Antimicrobianos, Centro Hospitalar Universitário Lisboa Norte EPE, Lisbon, Portugal
| | - Cátia Caneiras
- Laboratório de Microbiologia na Saúde Ambiental, Laboratório Associado TERRA, Instituto de Saúde Ambiental, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
- Egas Moniz Center for Interdisciplinary Research (CiiEM), Egas Moniz School of Health and Science, Monte da Caparica, Portugal
- Instituto de Medicina Preventiva e Saúde Pública, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
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Aslan AT, Ezure Y, Horcajada JP, Harris PNA, Paterson DL. In vitro, in vivo and clinical studies comparing the efficacy of ceftazidime-avibactam monotherapy with ceftazidime-avibactam-containing combination regimens against carbapenem-resistant Enterobacterales and multidrug-resistant Pseudomonas aeruginosa isolates or infections: a scoping review. Front Med (Lausanne) 2023; 10:1249030. [PMID: 37727767 PMCID: PMC10506411 DOI: 10.3389/fmed.2023.1249030] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 08/23/2023] [Indexed: 09/21/2023] Open
Abstract
Introduction Carbapenem-resistant Enterobacterales (CRE) and multidrug-resistant Pseudomonas aeruginosa (MDR-PA) infections are associated with a high risk of morbidity, mortality, and treatment costs. We aimed to evaluate in vitro, in vivo and clinical studies comparing the efficacy of ceftazidime-avibactam (CZA) combination regimens with CZA alone against CRE and/or MDR-PA isolates or infections. Methods We systematically reviewed the relevant literature in CINAHL/MEDLINE, Pubmed, Cochrane, Web of Science, Embase, and Scopus until December 1, 2022. Review articles, grey literature, abstracts, comments, editorials, non-peer reviewed articles, non-English articles, and in vitro synergy studies conducted on single isolates were excluded. Results 22 in vitro, 7 in vivo and 20 clinical studies were evaluated. In vitro studies showed reliable synergy between CZA and aztreonam against metallo-β-lactamase (MBL)-producing isolates. Some studies indicated good in vitro synergy between CZA and amikacin, meropenem, fosfomycin and polymyxins against CRE isolates. For MDR-PA isolates, there are comparatively fewer in vitro or in vivo studies. In observational clinical studies, mortality, clinical cure, adverse events, and development of CZA resistance after exposure were generally similar in monotherapy and combination therapy groups. However, antibiotic-related nephrotoxicity and infection relapses were higher in patients receiving CZA combination therapies. Discussion The benefit, if any, of CZA combination regimens in MDR-PA infections is elusive, as very few clinical studies have included these infections. There is no currently documented clinical benefit for the use of CZA combination regimens rather than CZA monotherapy. CZA combined with aztreonam for serious infections due to MBL producers should be evaluated by randomized controlled trials. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278552, CRD42021278552.
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Affiliation(s)
- Abdullah Tarık Aslan
- Faculty of Medicine, UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Yukiko Ezure
- Faculty of Medicine, UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
| | - Juan Pablo Horcajada
- Faculty of Medicine, UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
- Infectious Diseases Department, Hospital del Mar, Institut Hospital Del Mar d’Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBERINFEC, ISCIII – CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, Madrid, Spain
| | - Patrick N. A. Harris
- Faculty of Medicine, UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD, Australia
- Central Microbiology, Pathology Queensland, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - David L. Paterson
- ADVANCE-ID, Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
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Kothari A, Kherdekar R, Mago V, Uniyal M, Mamgain G, Kalia RB, Kumar S, Jain N, Pandey A, Omar BJ. Age of Antibiotic Resistance in MDR/XDR Clinical Pathogen of Pseudomonas aeruginosa. Pharmaceuticals (Basel) 2023; 16:1230. [PMID: 37765038 PMCID: PMC10534605 DOI: 10.3390/ph16091230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/15/2023] [Accepted: 08/23/2023] [Indexed: 09/29/2023] Open
Abstract
Antibiotic resistance in Pseudomonas aeruginosa remains one of the most challenging phenomena of everyday medical science. The universal spread of high-risk clones of multidrug-resistant/extensively drug-resistant (MDR/XDR) clinical P. aeruginosa has become a public health threat. The P. aeruginosa bacteria exhibits remarkable genome plasticity that utilizes highly acquired and intrinsic resistance mechanisms to counter most antibiotic challenges. In addition, the adaptive antibiotic resistance of P. aeruginosa, including biofilm-mediated resistance and the formation of multidrug-tolerant persisted cells, are accountable for recalcitrance and relapse of infections. We highlighted the AMR mechanism considering the most common pathogen P. aeruginosa, its clinical impact, epidemiology, and save our souls (SOS)-mediated resistance. We further discussed the current therapeutic options against MDR/XDR P. aeruginosa infections, and described those treatment options in clinical practice. Finally, other therapeutic strategies, such as bacteriophage-based therapy and antimicrobial peptides, were described with clinical relevance.
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Affiliation(s)
- Ashish Kothari
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Radhika Kherdekar
- Department of Dentistry, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Vishal Mago
- Department of Burn and Plastic Surgery, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Madhur Uniyal
- Department of Trauma Surgery, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Garima Mamgain
- Department of Biochemistry, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Roop Bhushan Kalia
- Department of Orthopaedics, All India Institute of Medical Sciences, Rishikesh 249203, India;
| | - Sandeep Kumar
- Department of Cellular Biology and Anatomy, Augusta University, Augusta, GA 30912, USA;
| | - Neeraj Jain
- Department of Medical Oncology, All India Institute of Medical Sciences, Rishikesh 249203, India
- Division of Cancer Biology, Central Drug Research Institute, Lucknow 226031, India
| | - Atul Pandey
- Department of Entomology, University of Kentucky, Lexington, KY 40503, USA
| | - Balram Ji Omar
- Department of Microbiology, All India Institute of Medical Sciences, Rishikesh 249203, India;
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Baltas I, Gilchrist M, Koutoumanou E, Gibani MM, Meiring JE, Otu A, Hettle D, Thompson A, Price JR, Crepet A, Atomode A, Crocker-Buque T, Spinos D, Guyver H, Tausan M, Somasunderam D, Thoburn M, Chan C, Umpleby H, Sharp B, Chivers C, Vaghela DS, Shah RJ, Foster J, Hume A, Smith C, Asif A, Mermerelis D, Reza MA, Haigh DA, Lamb T, Karatzia L, Bramley A, Kadam N, Kavallieros K, Garcia-Arias V, Democratis J, Waddington CS, Moore LSP, Aiken AM. Exploring the views of infection consultants in England on a novel delinked funding model for antimicrobials: the SMASH study. JAC Antimicrob Resist 2023; 5:dlad091. [PMID: 37533762 PMCID: PMC10391702 DOI: 10.1093/jacamr/dlad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023] Open
Abstract
Objectives A novel 'subscription-type' funding model was launched in England in July 2022 for ceftazidime/avibactam and cefiderocol. We explored the views of infection consultants on important aspects of the delinked antimicrobial funding model. Methods An online survey was sent to all infection consultants in NHS acute hospitals in England. Results The response rate was 31.2% (235/753). Most consultants agreed the model is a welcome development (69.8%, 164/235), will improve treatment of drug-resistant infections (68.5%, 161/235) and will stimulate research and development of new antimicrobials (57.9%, 136/235). Consultants disagreed that the model would lead to reduced carbapenem use and reported increased use of cefiderocol post-implementation. The presence of an antimicrobial pharmacy team, requirement for preauthorization by infection specialists, antimicrobial stewardship ward rounds and education of infection specialists were considered the most effective antimicrobial stewardship interventions. Under the new model, 42.1% (99/235) of consultants would use these antimicrobials empirically, if risk factors for antimicrobial resistance were present (previous infection, colonization, treatment failure with carbapenems, ward outbreak, recent admission to a high-prevalence setting).Significantly higher insurance and diversity values were given to model antimicrobials compared with established treatments for carbapenem-resistant infections, while meropenem recorded the highest enablement value. Use of both 'subscription-type' model drugs for a wide range of infection sites was reported. Respondents prioritized ceftazidime/avibactam for infections by bacteria producing OXA-48 and KPC and cefiderocol for those producing MBLs and infections with Stenotrophomonas maltophilia, Acinetobacter spp. and Burkholderia cepacia. Conclusions The 'subscription-type' model was viewed favourably by infection consultants in England.
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Affiliation(s)
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, London, UK
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Eirini Koutoumanou
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Malick M Gibani
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - James E Meiring
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Akaninyene Otu
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Hettle
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ameeka Thompson
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James R Price
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Anna Crepet
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | | | - Dimitrios Spinos
- Department of ENT, Head and Neck Surgery, Gloucester Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Hudson Guyver
- James Paget University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Matija Tausan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Maxwell Thoburn
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cathleen Chan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Umpleby
- Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Bethany Sharp
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Callum Chivers
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ronak J Shah
- Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Foster
- Directorate of Pharmacy, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Amy Hume
- Directorate of Pharmacy, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Christopher Smith
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ammara Asif
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | | | - Thomas Lamb
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People’s Democratic Republic
| | | | | | - Nikhil Kadam
- Mid and South Essex NHS Trust, Westcliff-on-Sea, UK
| | | | | | - Jane Democratis
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | | | - Luke S P Moore
- Imperial College Healthcare NHS Trust, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, NIHR Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Alexander M Aiken
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
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9
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Liu YC, Lu CY, Yen TY, Chang LY, Chen JM, Lee PI, Huang LM. Clinical characteristics and outcomes of carbapenem-resistant Enterobacterales bacteremia in pediatric patients. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2023; 56:84-92. [PMID: 36376217 DOI: 10.1016/j.jmii.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 09/28/2022] [Accepted: 09/30/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND/PURPOSE Clinical data on carbapenem-resistant Enterobacterales (CRE) bacteremia in the pediatric population are limited. This study investigated the clinical characteristics and outcomes of pediatric CRE bacteremia. METHODS Clinical data on bacteremia caused by carbapenem-susceptible and carbapenem-resistant Enterobacterales, including Escherichia coli, Klebsiella spp., Enterobacter spp., Serratia marcescens, Proteus mirabilis, Citrobacter spp., and Morganella spp., in pediatric patients from a children's hospital in Taiwan were retrospectively retrieved and analyzed. RESULTS From January 2013 to December 2021, 471 clinical isolates of Enterobacterales bacteremia were identified in 451 episodes from 379 pediatric patients. Among all the isolates, the predominant species were E. coli (199/471, 42.2%), Klebsiella spp. (168/471, 35.6%), and Enterobacter spp. (59/471, 12.5%), with carbapenem-resistance rates of 1.5%, 11.9%, and 25.0%, respectively. Overall, 40 (8.4%) showed a carbapenem resistance phenotype. Patients' all-cause mortality rate at 14 days was significantly higher in CRE bacteremia episodes than non-CRE ones (12.5% vs. 3.6%, p < 0.05). The predicting factor of a CRE bacteremia episode was the causative agent of Enterobacter spp. (adjusted OR of 2.551, CI 1.073-6.066, p < 0.05) and ESBL-producing phenotype (adjusted OR 14.268, CI 5.120-39.762, p < 0.001). CONCLUSION Bloodstream infections caused by CRE are associated with a higher mortality rate in the pediatric population. Attention must be paid to preventing and managing pediatric patients with CRE infections.
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Affiliation(s)
- Yu-Cheng Liu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Yi Lu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan.
| | - Ting-Yu Yen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Luan-Yin Chang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Jong-Min Chen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Ping-Ing Lee
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Li-Min Huang
- Division of Pediatric Infectious Diseases, Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; College of Medicine, National Taiwan University, Taipei, Taiwan
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10
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Chowdhury AR, Mukherjee D, Singh AK, Chakravortty D. Loss of outer membrane protein A (OmpA) impairs the survival of Salmonella Typhimurium by inducing membrane damage in the presence of ceftazidime and meropenem. J Antimicrob Chemother 2022; 77:3376-3389. [PMID: 36177811 DOI: 10.1093/jac/dkac327] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES Salmonella enterica serovar Typhimurium is one of the significant non-typhoidal Salmonella serovars that causes gastroenteritis. The rapid development of antimicrobial resistance necessitates studying new antimicrobials and their therapeutic targets in this pathogen. Our study aimed to investigate the role of four prominent outer membrane porins of S. Typhimurium, namely OmpA, OmpC, OmpD and OmpF, in developing resistance against ceftazidime and meropenem. METHODS The antibiotic-mediated inhibition of bacterial growth was determined by measuring the absorbance and the resazurin assay. DiBAC4 (Bis-(1,3-Dibutylbarbituric Acid)Trimethine Oxonol), 2,7-dichlorodihydrofluoroscein diacetate (DCFDA) and propidium iodide were used to determine the outer membrane depolarization, reactive oxygen species (ROS) generation and subsequent killing of Salmonella. The expression of oxidative stress-response and efflux pump genes was quantified by quantitative RT-qPCR. HPLC was done to determine the amount of antibiotics that entered the bacteria. The damage to the bacterial outer membrane was studied by confocal and atomic force microscopy. The in vivo efficacy of ceftazidime and meropenem were tested in the C57BL/6 mouse model. RESULTS Deleting ompA reduced the survival of Salmonella in the presence of ceftazidime and meropenem. Massive outer membrane depolarization and reduced expression of oxidative stress-response genes in S. Typhimurium ΔompA hampered its growth in the presence of antibiotics. The enhanced uptake of antibiotics and decreased expression of efflux pump genes in S. Typhimurium ΔompA resulted in damage to the bacterial outer membrane. The clearance of the S. Typhimurium ΔompA from C57BL/6 mice with ceftazidime treatment proved the role of OmpA in rendering protection against β-lactam antibiotics. CONCLUSIONS OmpA protects S. Typhimurium from two broad-spectrum β-lactam antibiotics, ceftazidime and meropenem, by maintaining the stability of the outer membrane.
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Affiliation(s)
- Atish Roy Chowdhury
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, Karnataka 560012, India.,Division of Biological Sciences, Indian Institute of Science, Bangalore, Karnataka 560012, India
| | - Debapriya Mukherjee
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, Karnataka 560012, India.,Division of Biological Sciences, Indian Institute of Science, Bangalore, Karnataka 560012, India
| | - Ashish Kumar Singh
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, Karnataka 560012, India.,Division of Biological Sciences, Indian Institute of Science, Bangalore, Karnataka 560012, India
| | - Dipshikha Chakravortty
- Department of Microbiology and Cell Biology, Indian Institute of Science, Bangalore, Karnataka 560012, India.,Division of Biological Sciences, Indian Institute of Science, Bangalore, Karnataka 560012, India.,School of Biology, Indian Institute of Science Education and Research, Thiruvananthapuram, Kerala 695551, India
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11
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Simon M, Gerlach RG, Pfeifer Y, Pfennigwerth N, Gatermann SG, Schröder A, Hiergeist A, Hamprecht A, Rügamer T, Gessner A, Jantsch J. Increased zinc levels facilitate phenotypic detection of ceftazidime-avibactam resistance in metallo-β-lactamase-producing Gram-negative bacteria. Front Microbiol 2022; 13:977330. [PMID: 36483203 PMCID: PMC9723239 DOI: 10.3389/fmicb.2022.977330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/17/2022] [Indexed: 01/25/2023] Open
Abstract
Ceftazidime-avibactam is one of the last resort antimicrobial agents for the treatment of carbapenem-resistant, Gram-negative bacteria. Metallo-β-lactamase-producing bacteria are considered to be ceftazidime-avibactam resistant. Here, we evaluated a semi-automated antimicrobial susceptibility testing system regarding its capability to detect phenotypic ceftazidime-avibactam resistance in 176 carbapenem-resistant, metallo-β-lactamase-producing Enterobacterales and Pseudomonas aeruginosa isolates. Nine clinical isolates displayed ceftazidime-avibactam susceptibility in the semi-automated system and six of these isolates were susceptible by broth microdilution, too. In all nine isolates, metallo-β-lactamase-mediated hydrolytic activity was demonstrated with the EDTA-modified carbapenemase inactivation method. As zinc is known to be an important co-factor for metallo-β-lactamase activity, test media of the semi-automated antimicrobial susceptibility testing system and broth microdilution were supplemented with zinc. Thereby, the detection of phenotypic resistance was improved in the semi-automated system and in broth microdilution. Currently, ceftazidime-avibactam is not approved as treatment option for infections by metallo-β-lactamase-producing, Gram-negative bacteria. In infections caused by carbapenem-resistant Gram-negatives, we therefore recommend to rule out the presence of metallo-β-lactamases with additional methods before initiating ceftazidime-avibactam treatment.
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Affiliation(s)
- Michaela Simon
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany,Institute for Medical Microbiology, Immunology, and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany,*Correspondence: Michaela Simon,
| | - Roman G. Gerlach
- Mikrobiologisches Institut-Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen and Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Erlangen, Germany
| | - Yvonne Pfeifer
- FG13 Nosocomial Pathogens and Antibiotic Resistance, Robert Koch Institute, Wernigerode, Germany
| | - Niels Pfennigwerth
- Department of Medical Microbiology, German National Reference Centre for Multidrug-Resistant Gram-negative Bacteria, Ruhr-University Bochum, Bochum, Germany
| | - Sören G. Gatermann
- Department of Medical Microbiology, German National Reference Centre for Multidrug-Resistant Gram-negative Bacteria, Ruhr-University Bochum, Bochum, Germany
| | - Agnes Schröder
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany,Department of Orthodontics, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Hiergeist
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany
| | - Axel Hamprecht
- Institute for Medical Microbiology, Immunology, and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany,Department of Medical Microbiology and Virology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany,Institute for Medical Microbiology and Virology, Oldenburg, Germany,German Centre for Infection Research, Partner Site Bonn-Cologne, Cologne, Germany
| | - Tamara Rügamer
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany
| | - André Gessner
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany
| | - Jonathan Jantsch
- Institute of Clinical Microbiology and Hygiene, University Hospital of Regensburg, Regensburg, Germany,Institute for Medical Microbiology, Immunology, and Hygiene, University Hospital Cologne and Faculty of Medicine, University of Cologne, Cologne, Germany
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12
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In Vitro Mechanisms of Resistance Development to Imipenem-Relebactam in KPC-Producing Klebsiella pneumoniae. Antimicrob Agents Chemother 2022; 66:e0091822. [PMID: 36154170 DOI: 10.1128/aac.00918-22] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Carbapenem-resistant Enterobacterales, such as KPC-producing Klebsiella pneumoniae, represent a major threat to public health. Novel drug combinations including imipenem-relebactam (IPM-REL) have recently been introduced and have been shown to exhibit excellent activity toward such strains. However, there has recently been reports of the in vivo emergence of IPM-REL resistance in KPC-producing K. pneumoniae. Here, we evaluated, in vitro, the nature of the mutations that lead to IPM-REL resistance in 5 KPC-producing K. pneumoniae strains, including 2 that produce KPC enzymes conferring ceftazidime-avibactam resistance. An in vitro multi-step selection assay was performed and corresponding mutants obtained. Mutations were identified in OmpK36 as well as 2 different mutant derivatives of KPC. Mutant strains exhibited decreased susceptibility to β-lactams, including the carbapenems, and meropenem-vaborbactam (MEM-VAB). Expression of blaKPC gene variants in an Escherichia coli recombinant strain resulted in a concomitant increased susceptibility to carbapenems and decreased susceptibility to CAZ-AVI, and enzymatic assays showed that the inhibitory activity of both AVI and REL was significantly lowered for both KPC mutants compared to parental enzymes. Complementation assays showed that OmpK36 plays a major role in IPM-REL resistance as well resistance to other ß-lactams and β-lactam/ß-lactamase inhibitor combinations. Overall, this study showed that (i) IPM-REL resistant strains can be obtained from CAZ-AVI-susceptible or -resistant KPC producers, (ii) selection of IPM-REL resistance has a collateral effect on MEM-VAB susceptibility - indicative of shared resistance mechanisms, (iii) and mutations in the KPC sequence may be obtained using IPM-REL selection leading to the possibility of vertical and horizontal transfer of this resistance trait.
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13
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Mushtaq S, Garello P, Vickers A, Woodford N, Livermore DM. Activity of ertapenem/zidebactam (WCK 6777) against problem Enterobacterales. J Antimicrob Chemother 2022; 77:2772-2778. [PMID: 35972407 PMCID: PMC9384802 DOI: 10.1093/jac/dkac280] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/26/2022] [Indexed: 12/03/2022] Open
Abstract
Background Secondary healthcare will remain pressured for some years, both because SARS-CoV-2 will circulate as a nosocomial pathogen, and owing to backlogs of patients awaiting delayed elective procedures. These stresses will drive the use of Outpatient Parenteral Antibiotic Therapy (OPAT), which will need to cover increasingly resistant Gram-negative opportunists. We evaluated the activity of ertapenem/zidebactam, proposed for 2 + 2 g q24h administration. Materials and methods MICs were determined, by BSAC agar dilution, for 1632 Enterobacterales submitted to the UK national reference laboratory for investigation of antimicrobial resistance. Results Over 90% of Escherichia coli with AmpC, ESBLs, KPC, metallo- or OXA-48 carbapenemases were inhibited by ertapenem/zidebactam 1:1 at ertapenem’s current 0.5 mg/L breakpoint. For other major Enterobacterales, the proportions inhibited by ertapenem/zidebactam 1:1 at 0.5 mg/L were mostly 65% to 90% but were lower for Klebsiella pneumoniae/oxytoca with metallo- or OXA-48 β-lactamases. However, animal studies support an 8 mg/L breakpoint for ertapenem/zidebactam, based on a shortened T>MIC being needed compared with ertapenem alone. On this basis ertapenem/zidebactam would count as active against 90%–100% of isolates in all groups except K. pneumoniae/oxytoca with MBLs (±OXA-48), where MICs and percent susceptibility vary substantially even with inocula within the BSAC acceptable range. Conclusions Ertapenem/zidebactam has a proposed once-daily regimen well suited to OPAT. Even on highly conservative breakpoint projections, it has potential against MDR E. coli, including metallo-carbapenemase producers. If trial data sustain the 8 mg/L breakpoint indicated by animal experiments, its potential will extend widely across infections due to ESBL-, AmpC- and carbapenemase-producing Enterobacterales.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Reference Services Division, United Kingdom Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Paolo Garello
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Reference Services Division, United Kingdom Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Reference Services Division, United Kingdom Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Reference Services Division, United Kingdom Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK
| | - David M Livermore
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Reference Services Division, United Kingdom Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, UK.,Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
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14
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OXA-48-Like β-Lactamases: Global Epidemiology, Treatment Options, and Development Pipeline. Antimicrob Agents Chemother 2022; 66:e0021622. [PMID: 35856662 PMCID: PMC9380527 DOI: 10.1128/aac.00216-22] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Modern medicine is threatened by the rising tide of antimicrobial resistance, especially among Gram-negative bacteria, where resistance to β-lactams is most often mediated by β-lactamases. The penicillin and cephalosporin ascendancies were, in their turn, ended by the proliferation of TEM penicillinases and CTX-M extended-spectrum β-lactamases. These class A β-lactamases have long been considered the most important. For carbapenems, however, the threat is increasingly from the insidious rise of a class D carbapenemase, OXA-48, and its close relatives. Over the past 20 years, OXA-48 and "OXA-48-like" enzymes have proliferated to become the most prevalent enterobacterial carbapenemases across much of Europe, Northern Africa, and the Middle East. OXA-48-like enzymes are notoriously difficult to detect because they often cause only low-level in vitro resistance to carbapenems, meaning that the true burden is likely underestimated. Despite this, they are associated with carbapenem treatment failures. A highly conserved incompatibility complex IncL plasmid scaffold often carries blaOXA-48 and may carry other antimicrobial resistance genes, leaving limited treatment options. High conjugation efficiency means that this plasmid is sometimes carried by multiple Enterobacterales in a single patient. Producers evade most β-lactam-β-lactamase inhibitor combinations, though promising agents have recently been licensed, notably ceftazidime-avibactam and cefiderocol. The molecular machinery enabling global spread, current treatment options, and the development pipeline of potential new therapies for Enterobacterales that produce OXA-48-like β-lactamases form the focus of this review.
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15
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Jean SS, Lee YL, Hsu CW, Hsueh PR. In vitro susceptibilities of isolates of potentially naturally inducible chromosomal AmpC-producing metallo-β-lactamase-negative carbapenem-resistant Enterobacterales species to ceftazidime-avibactam: Data from the Antimicrobial Testing Leadership and Surveillance Programme, 2012-2019. Int J Antimicrob Agents 2022; 60:106617. [PMID: 35718266 DOI: 10.1016/j.ijantimicag.2022.106617] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 04/28/2022] [Accepted: 06/12/2022] [Indexed: 11/17/2022]
Abstract
In total, 74,570 potentially naturally inducible chromosomal AmpC-producing (PNIC-AmpC) Enterobacterales isolates included in the Antimicrobial Testing Leadership and Surveillance Programme were obtained worldwide from 2012 to 2019 (22,503 from 2012 to 2014 and 52,067 from 2015 to 2019). One hundred seventeen and 711 isolates obtained in 2012-2014 and 2015-2019, respectively, were carbapenem-resistant Enterobacterales (PNIC-AmpC-CRE). The minimum inhibitory concentrations of ceftazidime-avibactam for these isolates against were determined using the broth microdilution method. Genes encoding different Ambler classes of β-lactamases were investigated using multiplex PCR. After 97 isolates harboring genes encoding metallo-β-lactamases (MβL) were excluded, 731 PNIC-AmpC MβL-negative CRE isolates (101 from 2012 to 2014 and 630 from 2015 to 2019) were included in this study. Enterobacter cloacae complex species, Escherichia coli, and Citrobacter freundii complex species accounted for 36.3% (n = 265), 30.4% (n = 222), and 11.8% (n = 86), respectively, followed by Providencia species (n = 72), Serratia species (n = 52), and Klebsiella aerogenes (n = 34). The resistance rates to ceftazidime-avibactam for the overall PNIC-AmpC MβL-negative CRE isolates differed markedly between the two periods (35.6% vs. 63.3%, P < 0.001). Similar trends were observed for the MβL-negative-CR-E. cloacae complex species (47.4% vs. 65.2%; P = 0.046) and MβL-negative-CR-E. coli (16.2% vs. 63.8%; P < 0.001) but not for MβL-negative-CR-C. freundii complex species (40% vs. 62%; P = 0.153). Amongst the PNIC-AmpC MβL-negative CRE isolates, resistance rates to ceftazidime-avibactam worsened. Caution should be taken when empirically prescribing ceftazidime-avibactam for infections caused by PNIC-AmpC-CRE before susceptibility data are available.
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Affiliation(s)
- Shio-Shin Jean
- Departments of Internal Medicine and Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan; Department of Pharmacy, College of Pharmacy and Health care, Tajen University, Pingtung, Taiwan
| | - Yu-Lin Lee
- Department of Internal Medicine, Changhua Christian Hospital, Changhua, Taiwan
| | - Chin-Wang Hsu
- Departments of Internal Medicine and Critical Care Medicine, Min-Sheng General Hospital, Taoyuan, Taiwan; Department of Pharmacy, College of Pharmacy and Health care, Tajen University, Pingtung, Taiwan
| | - Po-Ren Hsueh
- Departments of Laboratory Medicine and Internal Medicine, China Medical University Hospital, School of Medicine, China Medical University, Taichung, Taiwan; School of Medicine, China Medical University, Taichung, Taiwan; PhD Program for Aging, School of Medicine, China Medical University, Taichung, Taiwan; Departments of Laboratory Medicine and Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan.
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16
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Cruz-López F, Martínez-Meléndez A, Morfin-Otero R, Rodriguez-Noriega E, Maldonado-Garza HJ, Garza-González E. Efficacy and In Vitro Activity of Novel Antibiotics for Infections With Carbapenem-Resistant Gram-Negative Pathogens. Front Cell Infect Microbiol 2022; 12:884365. [PMID: 35669117 PMCID: PMC9163340 DOI: 10.3389/fcimb.2022.884365] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/19/2022] [Indexed: 12/15/2022] Open
Abstract
Infections by Gram-negative multi-drug resistant (MDR) bacterial species are difficult to treat using available antibiotics. Overuse of carbapenems has contributed to widespread resistance to these antibiotics; as a result, carbapenem-resistant Enterobacterales (CRE), A. baumannii (CRAB), and P. aeruginosa (CRPA) have become common causes of healthcare-associated infections. Carbapenems, tigecycline, and colistin are the last resource antibiotics currently used; however, multiple reports of resistance to these antimicrobial agents have been documented worldwide. Recently, new antibiotics have been evaluated against Gram-negatives, including plazomicin (a new aminoglycoside) to treat CRE infection, eravacycline (a novel tetracycline) with in vitro activity against CRAB, and cefiderocol (a synthetic conjugate) for the treatment of nosocomial pneumonia by carbapenem-non-susceptible Gram-negative isolates. Furthermore, combinations of known β-lactams with recently developed β-lactam inhibitors, such as ceftazidime-avibactam, ceftolozane-tazobactam, ceftazidime-tazobactam, and meropenem-vaborbactam, has been suggested for the treatment of infections by extended-spectrum β-lactamases, carbapenemases, and AmpC producer bacteria. Nonetheless, they are not active against all carbapenemases, and there are reports of resistance to these combinations in clinical isolates.This review summarizes and discusses the in vitro and clinical evidence of the recently approved antibiotics, β-lactam inhibitors, and those in advanced phases of development for treating MDR infections caused by Gram-negative multi-drug resistant (MDR) bacterial species.
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Affiliation(s)
- Flora Cruz-López
- Subdirección Académica de Químico Farmacéutico Biólogo, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Adrian Martínez-Meléndez
- Subdirección Académica de Químico Farmacéutico Biólogo, Facultad de Ciencias Químicas, Universidad Autónoma de Nuevo León, San Nicolás de los Garza, Mexico
| | - Rayo Morfin-Otero
- Instituto de Patología Infecciosa y Experimental "Dr. Francisco Ruiz Sánchez", Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Eduardo Rodriguez-Noriega
- Instituto de Patología Infecciosa y Experimental "Dr. Francisco Ruiz Sánchez", Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Héctor J Maldonado-Garza
- Servicio de Gastroenterología, Hospital Universitario 'Dr. José Eleuterio González', Universidad Autónoma de Nuevo León, Monterrey, Mexico
| | - Elvira Garza-González
- Laboratorio de Microbiología Molecular, Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Monterrey, Mexico
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17
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Nichols WW, Bradford PA, Lahiri SD, Stone GG. The primary pharmacology of ceftazidime/avibactam: in vitro translational biology. J Antimicrob Chemother 2022; 77:2321-2340. [PMID: 35665807 DOI: 10.1093/jac/dkac171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Previous reviews of ceftazidime/avibactam have focused on in vitro molecular enzymology and microbiology or the clinically associated properties of the combination. Here we take a different approach. We initiate a series of linked reviews that analyse research on the combination that built the primary pharmacology data required to support the clinical and business risk decisions to perform randomized controlled Phase 3 clinical trials, and the additional microbiological research that was added to the above, and the safety and chemical manufacturing and controls data, that constituted successful regulatory licensing applications for ceftazidime/avibactam in multiple countries, including the USA and the EU. The aim of the series is to provide both a source of reference for clinicians and microbiologists to be able to use ceftazidime/avibactam to its best advantage for patients, but also a case study of bringing a novel β-lactamase inhibitor (in combination with an established β-lactam) through the microbiological aspects of clinical development and regulatory applications, updated finally with a review of resistance occurring in patients under treatment. This first article reviews the biochemistry, structural biology and basic microbiology of the combination, showing that avibactam inhibits the great majority of serine-dependent β-lactamases in Enterobacterales and Pseudomonas aeruginosa to restore the in vitro antibacterial activity of ceftazidime. Translation to efficacy against infections in vivo is reviewed in the second co-published article, Nichols et al. (J Antimicrob Chemother 2022; dkac172).
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18
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Efficacy of Combination Therapies for the Treatment of Multi-Drug Resistant Gram-Negative Bacterial Infections Based on Meta-Analyses. Antibiotics (Basel) 2022; 11:antibiotics11040524. [PMID: 35453274 PMCID: PMC9027966 DOI: 10.3390/antibiotics11040524] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 02/05/2023] Open
Abstract
There is increasing evidence regarding the optimal therapeutic strategies for multidrug-resistant (MDR) bacteria that cause common infections and are resistant to existing antibiotics. Combination therapies, such as β-lactam combined with β-lactamase inhibitors or combination antibiotics, is a therapeutic strategy to overcome MDR bacteria. In recent years, the therapeutic options have expanded as certain combination drugs have been approved in more countries. However, only a handful of guidelines support these options, and the recommendations are based on low-quality evidence. This review describes the significance and efficacy of combination therapy as a therapeutic strategy against Gram-negative MDR pathogens based on previously reported meta-analyses.
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Alfei S, Schito AM. β-Lactam Antibiotics and β-Lactamase Enzymes Inhibitors, Part 2: Our Limited Resources. Pharmaceuticals (Basel) 2022; 15:ph15040476. [PMID: 35455473 PMCID: PMC9031764 DOI: 10.3390/ph15040476] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Revised: 04/08/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022] Open
Abstract
β-lactam antibiotics (BLAs) are crucial molecules among antibacterial drugs, but the increasing emergence of resistance to them, developed by bacteria producing β-lactamase enzymes (BLEs), is becoming one of the major warnings to the global public health. Since only a small number of novel antibiotics are in development, a current clinical approach to limit this phenomenon consists of administering proper combinations of β-lactam antibiotics (BLAs) and β-lactamase inhibitors (BLEsIs). Unfortunately, while few clinically approved BLEsIs are capable of inhibiting most class-A and -C serine β-lactamases (SBLEs) and some carbapenemases of class D, they are unable to inhibit most part of the carbapenem hydrolyzing enzymes of class D and the worrying metallo-β-lactamases (MBLEs) of class B. Particularly, MBLEs are a set of enzymes that catalyzes the hydrolysis of a broad range of BLAs by a zinc-mediated mechanism, and currently no clinically available molecule capable of inhibiting MBLEs exists. Additionally, new types of alarming “superbugs”, were found to produce the New Delhi metallo-β-lactamases (NDMs) encoded by increasing variants of a plasmid-mediated gene capable of rapidly spreading among bacteria of the same species and even among different species. Particularly, NDM-1 possesses a flexible hydrolysis mechanism that inactivates all BLAs, except for aztreonam. The present review provides first an overview of existing BLAs and the most clinically relevant BLEs detected so far. Then, the BLEsIs and their most common associations with BLAs already clinically applied and those still in development are reviewed.
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Affiliation(s)
- Silvana Alfei
- Department of Pharmacy (DIFAR), University of Genoa, Viale Cembrano, 4, 16148 Genoa, Italy
- Correspondence: ; Tel.: +39-010-355-2296
| | - Anna Maria Schito
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV, 6, 16132 Genoa, Italy;
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Recommendations to Synthetize Old and New β-Lactamases Inhibitors: A Review to Encourage Further Production. Pharmaceuticals (Basel) 2022; 15:ph15030384. [PMID: 35337181 PMCID: PMC8954882 DOI: 10.3390/ph15030384] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/15/2022] [Accepted: 03/19/2022] [Indexed: 01/06/2023] Open
Abstract
The increasing emergence of bacteria producing β-lactamases enzymes (BLEs), able to inactivate the available β-lactam antibiotics (BLAs), causing the hydrolytic opening of their β-lactam ring, is one of the global major warnings. According to Ambler classification, BLEs are grouped in serine-BLEs (SBLEs) of class A, C, and D, and metal-BLEs (MBLEs) of class B. A current strategy to restore no longer functioning BLAs consists of associating them to β-lactamase enzymes inhibitors (BLEsIs), which, interacting with BLEs, prevent them hydrolyzing to the associated antibiotic. Worryingly, the inhibitors that are clinically approved are very few and inhibit only most of class A and C SBLEs, leaving several class D and all MBLEs of class B untouched. Numerous non-clinically approved new molecules are in development, which have shown broad and ultra-broad spectrum of action, some of them also being active on the New Delhi metal-β-lactamase-1 (NDM-1), which can hydrolyze all available BLAs except for aztreonam. To not duplicate the existing review concerning this topic, we have herein examined BLEsIs by a chemistry approach. To this end, we have reviewed both the long-established synthesis adopted to prepare the old BLEsIs, those proposed to achieve the BLEsIs that are newly approved, and those recently reported to prepare the most relevant molecules yet in development, which have shown high potency, providing for each synthesis the related reaction scheme.
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The Role of Colistin in the Era of New β-Lactam/β-Lactamase Inhibitor Combinations. Antibiotics (Basel) 2022; 11:antibiotics11020277. [PMID: 35203879 PMCID: PMC8868358 DOI: 10.3390/antibiotics11020277] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 02/17/2022] [Accepted: 02/17/2022] [Indexed: 02/06/2023] Open
Abstract
With the current crisis related to the emergence of carbapenem-resistant Gram-negative bacteria (CR-GNB), classical treatment approaches with so-called “old-fashion antibiotics” are generally unsatisfactory. Newly approved β-lactam/β-lactamase inhibitors (BLBLIs) should be considered as the first-line treatment options for carbapenem-resistant Enterobacterales (CRE) and carbapenem-resistant Pseudomonas aeruginosa (CRPA) infections. However, colistin can be prescribed for uncomplicated lower urinary tract infections caused by CR-GNB by relying on its pharmacokinetic and pharmacodynamic properties. Similarly, colistin can still be regarded as an alternative therapy for infections caused by carbapenem-resistant Acinetobacter baumannii (CRAB) until new and effective agents are approved. Using colistin in combination regimens (i.e., including at least two in vitro active agents) can be considered in CRAB infections, and CRE infections with high risk of mortality. In conclusion, new BLBLIs have largely replaced colistin for the treatment of CR-GNB infections. Nevertheless, colistin may be needed for the treatment of CRAB infections and in the setting where the new BLBLIs are currently unavailable. In addition, with the advent of rapid diagnostic methods and novel antimicrobials, the application of personalized medicine has gained significant importance in the treatment of CRE infections.
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22
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Cui X, Lü Y, Yue C. Development and Research Progress of Anti-Drug Resistant Bacteria Drugs. Infect Drug Resist 2022; 14:5575-5593. [PMID: 34992385 PMCID: PMC8711564 DOI: 10.2147/idr.s338987] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 11/12/2021] [Indexed: 01/10/2023] Open
Abstract
Bacterial resistance has become increasingly serious because of the widespread use and abuse of antibiotics. In particular, the emergence of multidrug-resistant bacteria has posed a serious threat to human public health and attracted the attention of the World Health Organization (WHO) and the governments of various countries. Therefore, the establishment of measures against bacterial resistance and the discovery of new antibacterial drugs are increasingly urgent to better contain the emergence of bacterial resistance and provide a reference for the development of new antibacterial drugs. In this review, we discuss some antibiotic drugs that have been approved for clinical use and a partial summary of the meaningful research results of anti-drug resistant bacterial drugs in different fields, including the antibiotic drugs approved by the FDA from 2015 to 2020, the potential drugs against drug-resistant bacteria, the new molecules synthesized by chemical modification, combination therapy, drug repurposing, immunotherapy and other therapies.
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Affiliation(s)
- Xiangyi Cui
- Key Laboratory of Microbial Drugs Innovation and Transformation of Yan'an, School of Basic Medicine, Yan'an University, Yan'an, 716000, Shaanxi, People's Republic of China
| | - Yuhong Lü
- Key Laboratory of Microbial Drugs Innovation and Transformation of Yan'an, School of Basic Medicine, Yan'an University, Yan'an, 716000, Shaanxi, People's Republic of China.,Shaanxi Engineering & Technological Research Center for Conversation & Utilization of Regional Biological Resources, Yan'an University, Yan'an, 716000, Shaanxi, People's Republic of China
| | - Changwu Yue
- Key Laboratory of Microbial Drugs Innovation and Transformation of Yan'an, School of Basic Medicine, Yan'an University, Yan'an, 716000, Shaanxi, People's Republic of China.,Shaanxi Engineering & Technological Research Center for Conversation & Utilization of Regional Biological Resources, Yan'an University, Yan'an, 716000, Shaanxi, People's Republic of China
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How to Manage Pseudomonas aeruginosa Infections. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1386:425-445. [DOI: 10.1007/978-3-031-08491-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Selection of AmpC β-lactamase variants and metallo-β-lactamases leading to ceftolozane/tazobactam and ceftazidime/avibactam-resistance during treatment of MDR/XDR Pseudomonas aeruginosa infections. Antimicrob Agents Chemother 2021; 66:e0206721. [PMID: 34930034 DOI: 10.1128/aac.02067-21] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Infections caused by ceftolozane/tazobactam and ceftazidime/avibactam-resistant P. aeruginosa infections are an emerging concern. We aimed to analyze the underlying ceftolozane/tazobactam and ceftazidime/avibactam resistance mechanisms in all MDR/XDR P. aeruginosa isolates recovered during one year (2020) from patients with a documented P. aeruginosa infection. Fifteen isolates showing ceftolozane/tazobactam and ceftazidime/avibactam resistance were evaluated. Clinical conditions, previous positive cultures and β-lactams received in the previous month were reviewed for each patient. MICs were determined by broth microdilution. MLSTs and resistance mechanisms were determined using short- and long-read WGS. The impact of PDCs on β-lactam resistance was demonstrated by cloning into an ampC-deficient PAO1 derivative (PAOΔC) and construction of 3D models. Genetic support of acquired β-lactamases was determined in silico from high-quality hybrid assemblies. In most cases, the isolates were recovered after treatment with ceftolozane/tazobactam or ceftazidime/avibactam. Seven isolates from different STs owed their β-lactam resistance to chromosomal mutations and all displayed specific substitutions in PDC: Phe121Leu and Gly222Ser, Pro154Leu, Ala201Thr, Gly214Arg, ΔGly203-Glu219 and Glu219Lys. In the other eight isolates, the ST175 clone was overrepresented (6 isolates) and associated with IMP-28 and IMP-13, whereas two ST1284 isolates produced VIM-2. The cloned PDCs conferred enhanced cephalosporin resistance. 3D PDC models revealed rearrangements affecting residues involved in cephalosporin hydrolysis. Carbapenemases were chromosomal (VIM-2) or plasmid-borne (IMP-28, IMP-13), and associated with class-1 integrons located in Tn402-like transposition modules. Our findings highlight that cephalosporin/ß-lactamase inhibitors are potential selectors of MDR/XDR P. aeruginosa strains producing PDC variants or metallo-ß-lactamases. Judicious use of these agents is encouraged.
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Abstract
PURPOSE OF REVIEW To discuss the current literature on novel agents for the treatment of carbapenem-resistant nonfermenting Gram-negative bacteria (NF-GNB) infections. RECENT FINDINGS Some novel agents have recently become available that are expected to replace classical polymyxins as the first-line options for the treatment of carbapenem-resistant NF-GNB infections. SUMMARY In this narrative review, we provide a brief overview of the differential activity of various recently approved agents against NF-GNB most encountered in the daily clinical practice, as well as the results from phase-3 randomized clinical trials and large postapproval observational studies, with special focus on NF-GNB. Since resistance to novel agents has already been reported, the use of novel agents needs to be optimized, based on their differential activity (not only in terms of targeted bacteria, but also of resistance determinants), the local microbiological epidemiology, and the most updated pharmacokinetic/pharmacodynamic data. Large real-life experiences remain of crucial importance for further refining the optimal treatment of NF-GNB infections in the daily clinical practice.
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Castanheira M, Doyle TB, Collingsworth TD, Sader HS, Mendes RE. Increasing frequency of OXA-48-producing Enterobacterales worldwide and activity of ceftazidime/avibactam, meropenem/vaborbactam and comparators against these isolates. J Antimicrob Chemother 2021; 76:3125-3134. [PMID: 34459890 PMCID: PMC8598286 DOI: 10.1093/jac/dkab306] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/21/2021] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES To investigate the increase in the rates of OXA-48-like-producing isolates during 3 years of global surveillance. METHODS Among 55?>162 Enterobacterales isolates, 354 carbapenem-resistant isolates carried genes encoding OXA-48-like enzymes. Isolates were susceptibility tested for ceftazidime/avibactam and comparators by broth microdilution methods. Analysis of β-lactam resistance mechanisms and MLST was performed in silico using WGS data. RESULTS OXA-48-like-producing isolates increased from 0.5% (94/18 656) in 2016 to 0.9% (169/18?>808) in 2018. OXA-48 was the most common variant; isolates primarily were Klebsiella pneumoniae (318/354 isolates) from Europe and adjacent countries. MLST analysis revealed a diversity of STs, but K. pneumoniae belonging to ST395, ST23 and ST11 were observed most frequently. Thirty-nine isolates harboured MBLs and were resistant to most agents tested. The presence of blaCTX-M-15 (258 isolates), OmpK35 nonsense mutations (232) and OmpK36 alterations (316) was common among OXA-48 producers. Ceftazidime, cefepime and aztreonam susceptibility rates, when applying CLSI breakpoints, were 12%-15% lower for isolates carrying ESBLs alone and with either or both OmpK35 stop codons and OmpK36 alterations. Meropenem and, remarkably, meropenem/vaborbactam were affected by specific OmpK36 alterations when a deleterious mutation also was observed in OmpK35. These mechanisms caused a decrease of 12%-42% in the susceptibility rates for meropenem and meropenem/vaborbactam. Ceftazidime/avibactam susceptibility rates were >98.9%, regardless of the presence of additional β-lactam resistance mechanisms. CONCLUSIONS Guidelines for the treatment of infections caused by OXA-48-producing isolates are scarce and, as the dissemination of these isolates continues, studies are needed to help physicians understand treatment options for these infections.
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Meschiari M, Orlando G, Kaleci S, Bianco V, Sarti M, Venturelli C, Mussini C. Combined Resistance to Ceftolozane-Tazobactam and Ceftazidime-Avibactam in Extensively Drug-Resistant (XDR) and Multidrug-Resistant (MDR) Pseudomonas aeruginosa: Resistance Predictors and Impact on Clinical Outcomes Besides Implications for Antimicrobial Stewardship Programs. Antibiotics (Basel) 2021; 10:antibiotics10101224. [PMID: 34680805 PMCID: PMC8532599 DOI: 10.3390/antibiotics10101224] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 11/16/2022] Open
Abstract
A retrospective case-control study was conducted at Modena University Hospital from December 2017 to January 2019 to identify risk factors and predictors of MDR/XDR Pseudomonas aeruginosa (PA) isolation with resistance to ceftazidime/avibactam (CZA) and ceftolozane/tazobactam (C/T), and of mortality among patients infected/colonized. Among 111 PA isolates from clinical/surveillance samples, 60 (54.1%) were susceptible to both drugs (S-CZA-C/T), while 27 (24.3%) were resistant to both (R-CZA-C/T). Compared to patients colonized/infected with S-CZA-C/T, those with R-C/T + CZA PA had a statistically significantly higher Charlson comorbidity score, greater rate of previous PA colonization, longer time before PA isolation, more frequent presence of CVC, higher exposure to C/T and cephalosporins, longer hospital stay, and higher overall and attributable mortality. In the multivariable analysis, age, prior PA colonization, longer time from admission to PA isolation, diagnosis of urinary tract infection, and exposure to carbapenems were associated with the isolation of a R-C/T + CZA PA strain, while PA-related BSI, a comorbidity score > 7, and ICU stay were significantly associated with attributable mortality. C/T and CZA are important therapeutic resources for hard-to-treat PA-related infections, thus specific antimicrobial stewardship interventions should be prompted in order to avoid the development of this combined resistance, which would jeopardize the chance to treat these infections.
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Affiliation(s)
- Marianna Meschiari
- Infectious Disease Clinic, Policlinico University Hospital, 41122 Modena, Italy; (M.M.); (C.M.)
| | - Gabriella Orlando
- Infectious Disease Clinic, Policlinico University Hospital, 41122 Modena, Italy; (M.M.); (C.M.)
- Correspondence: ; Tel.: +39-059-422-5287
| | - Shaniko Kaleci
- Clinical and Experimental Medicine, University of Modena and Reggio Emilia, 41122 Modena, Italy;
| | - Vincenzo Bianco
- Infectious Disease Clinic, Cotugno Hospital, 80131 Naples, Italy;
| | - Mario Sarti
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, 41122 Modena, Italy; (M.S.); (C.V.)
| | - Claudia Venturelli
- Clinical Microbiology Laboratory, University of Modena and Reggio Emilia, 41122 Modena, Italy; (M.S.); (C.V.)
| | - Cristina Mussini
- Infectious Disease Clinic, Policlinico University Hospital, 41122 Modena, Italy; (M.M.); (C.M.)
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Wei M, Wang P, Wang S, Yang C, Gu LI. Rapid Detection and Differentiation of KPC and MBL Carbapenemases among Enterobacterales Isolates by a Modified Combined-Disk Test. Pol J Microbiol 2021; 70:387-394. [PMID: 34584532 PMCID: PMC8458999 DOI: 10.33073/pjm-2021-036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 07/12/2021] [Accepted: 07/28/2021] [Indexed: 12/30/2022] Open
Abstract
This study was conducted to develop a cheap, rapid, and accurate modified combined-disk test (mCDT) approach to detect and differentiate KPC and MBL carbapenemases among clinical carbapenem-resistant Enterobacterales (CRE) isolates and simultaneously distinguish them from carbapenem-susceptible Enterobacterales (CSE) isolates. A total of 163 CRE and 90 third-generation cephalosporin-resistant Enterobacterales isolates were tested using imipenem and meropenem disks and different concentrations of carbapenemase inhibitors. The optimal sensitivity and specificity for detecting KPC carbapenemase were 97.2% and 100%, respectively. The sensitivity and specificity for detecting MBL carbapenemase were 100% and 100% with imipenem or meropenem and carbapenemase inhibitors within six hours. The inhibitory zone diameter of 18 mm for imipenem or meropenem disks without inhibitor could distinguish CRE from CSE isolates. Therefore, this mCDT approach may be a useful tool in clinical laboratories to detect CRE isolates and differentiate KPC and MBL producers, which is beneficial for patient management and hospital infection prevention and control.
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Affiliation(s)
- Ming Wei
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Peng Wang
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shuai Wang
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chunxia Yang
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
| | - L I Gu
- Department of Infectious Diseases and Clinical Microbiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, People's Republic of China
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Mushtaq S, Meunier D, Vickers A, Woodford N, Livermore DM. Activity of imipenem/relebactam against Pseudomonas aeruginosa producing ESBLs and carbapenemases. J Antimicrob Chemother 2021; 76:434-442. [PMID: 33152755 DOI: 10.1093/jac/dkaa456] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Accepted: 10/05/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND ESBL- and carbapenemase-producing Pseudomonas aeruginosa are prevalent in, for example, the Middle East, Eastern Europe and Latin America, though rarer elsewhere. Because P. aeruginosa readily mutate to become carbapenem resistant via loss of OprD, isolates producing ESBLs are often as broadly resistant as those producing carbapenemases. We hypothesized that: (i) relebactam might overcome class A carbapenemases directly in P. aeruginosa; and (ii) relebactam's inhibition of AmpC, which gives a generalized potentiation of imipenem against the species, might restore imipenem susceptibility in OprD-deficient ESBL producers. METHODS MICs were determined using CLSI agar dilution for P. aeruginosa isolates producing ESBLs, principally VEB types, and for those producing GES-5, KPC and other carbapenemases. RESULTS Relebactam potentiated imipenem by around 4-8-fold for most P. aeruginosa isolates producing VEB and other ESBLs; however, MICs were typically only reduced to 4-16 mg/L, thus mostly remaining above EUCAST's susceptible range and only partly overlapping CLSI's intermediate range. Strong (approx. 64-fold) potentiation was seen for isolates producing KPC carbapenemases, but only 2-fold synergy for those with GES-5. Predictably, potentiation was not seen for isolates with class B or D carbapenemase activity. CONCLUSIONS Relebactam did potentiate imipenem against ESBL-producing P. aeruginosa, which are mostly imipenem resistant via OprD loss, but this potentiation was generally insufficient to reduce imipenem MICs to the clinical range. Imipenem resistance owing to KPC carbapenemases was reversed by relebactam in P. aeruginosa, just as for Enterobacterales.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Danièle Meunier
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - David M Livermore
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK.,Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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Mushtaq S, Garello P, Vickers A, Woodford N, Livermore DM. Activity of cefepime/zidebactam (WCK 5222) against 'problem' antibiotic-resistant Gram-negative bacteria sent to a national reference laboratory. J Antimicrob Chemother 2021; 76:1511-1522. [PMID: 33760082 DOI: 10.1093/jac/dkab067] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/11/2021] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Triple-action diazabicyclooctanes, e.g. zidebactam, combine β-lactamase inhibition, antibacterial activity, and 'enhancement' of PBP3-targeted β-lactams. OBJECTIVES To examine the activity of cefepime/zidebactam against consecutive 'problem' Gram-negative bacteria referred to the UK national reference laboratory. METHODS MICs were determined by BSAC agar dilution for 1632 Enterobacterales, 745 Pseudomonas aeruginosa and 450 other non-fermenters, categorized by carbapenemase detection and interpretive reading. RESULTS Universal susceptibility to cefepime/zidebactam 8 + 8 mg/L was seen for otherwise multidrug-resistant Enterobacterales with AmpC, extended-spectrum, K1, KPC and OXA-48-like β-lactamases, or with impermeability and 'unassigned' mechanisms. Unlike ceftazidime/avibactam and all other comparators, cefepime/zidebactam 8 + 8 mg/L also inhibited most (190/210, 90.5%) Enterobacterales with MBLs. Resistance in the remaining minority of MBL producers, and in 13/24 with both NDM MBLs and OXA-48-like enzymes, was associated with Klebsiella pneumoniae ST14. For Pseudomonas aeruginosa, MICs of cefepime/zidebactam rose with efflux grade, but exceeded 8 + 8 mg/L for only 11/85 isolates even in the highly-raised efflux group. Among 103 P. aeruginosa with ESBLs or MBLs, 97 (94.5%) were inhibited by cefepime/zidebactam 8 + 8 mg/L whereas fewer than 15% were susceptible to any comparator. MICs for Acinetobacter baumannii with acquired OXA carbapenemases clustered around 8 + 8 to 32 + 32 mg/L, with higher values for MBL producers. A strong enhancer effect augmented activity against many isolates that were highly resistant to cefepime and zidebactam alone and which had mechanisms not inhibited by zidebactam. CONCLUSIONS Assuming successful clinical trials, cefepime/zidebactam has scope to widely overcome critical resistances in both Enterobacterales and non-fermenters.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Paolo Garello
- Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK
| | - David M Livermore
- Antimicrobial Resistance and Healthcare-Associated Infections Reference Unit, Public Health England, 61 Colindale Avenue, London NW9 5EQ, UK.,Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK
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31
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Livermore DM, Nicolau DP, Hopkins KL, Meunier D. Carbapenem-Resistant Enterobacterales, Carbapenem Resistant Organisms, Carbapenemase-Producing Enterobacterales, and Carbapenemase-Producing Organisms: Terminology Past its "Sell-By Date" in an Era of New Antibiotics and Regional Carbapenemase Epidemiology. Clin Infect Dis 2021; 71:1776-1782. [PMID: 32025698 DOI: 10.1093/cid/ciaa122] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 02/04/2020] [Indexed: 12/20/2022] Open
Abstract
Carbapenem resistance in Gram-negative bacteria is a public health concern. Consequently, numerous government and agency reports discuss carbapenem-resistant Enterobacterales (CRE) and carbapenem-resistant organisms (CROs). Unfortunately, these terms are fuzzy. Do they include (1) Proteeae with inherent imipenem resistance; (2) porin-deficient Enterobacterales resistant to ertapenem but not other carbapenems; (3) Enterobacterales with OXA-48-like enzymes that remain "carbapenem susceptible" at breakpoint; and (4) Pseudomonas aeruginosa that merely lack porin OprD? Counting CPE or CPOs is better but still insufficient, because different carbapenemases have differing treatment implications, particularly for new β-lactam/β-lactamase inhibitor combinations. At the least, it is essential for authors, journals, and regulatory agencies to specify the carbapenemases meant. The future may demand even greater precision, for mutations can alter hydrolytic activity, and the ability to confer resistance, within carbapenemase families.
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Affiliation(s)
- David M Livermore
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, Connecticut, USA
| | - Katie L Hopkins
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Danièle Meunier
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
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Nguyen LP, Park CS, Pinto NA, Lee H, Seo HS, Vu TN, Mai H, Pham AHT, Jang E, Cho YL, Goglin K, Nguyen K, White R, D’Souza R, Fouts DE, Yong D. In Vitro Activity of a Novel Siderophore-Cephalosporin LCB10-0200 (GT-1), and LCB10-0200/Avibactam, against Carbapenem-Resistant Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa Strains at a Tertiary Hospital in Korea. Pharmaceuticals (Basel) 2021; 14:370. [PMID: 33923801 PMCID: PMC8072773 DOI: 10.3390/ph14040370] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 12/17/2022] Open
Abstract
The siderophore-antibiotic conjugate LCB10-0200 (a.k.a. GT-1) has been developed to combat multidrug-resistant Gram-negative bacteria. In this study, the in vitro activity of LCB10-0200 and LCB10-0200/avibactam (AVI) has been investigated against carbapenem-resistant Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. Minimal inhibitory concentrations (MICs) of LCB10-0200, LCB10-0200/AVI, aztreonam, aztreonam/AVI, ceftazidime, ceftazidime/AVI, and meropenem were measured using the agar dilution method. Whole genome sequencing was performed using Illumina and the resistome was analyzed. LCB10-0200 displayed stronger activity than the comparator drugs in meropenem-resistant E. coli and K. pneumoniae, and the addition of AVI enhanced the LCB10-0200 activity to MIC ≤ 0.12 mg/L for 90.5% of isolates. In contrast, whereas LCB10-0200 alone showed potent activity against meropenem-resistant A. baumannii and P. aeruginosa at MIC ≤ 4 mg/L for 84.3% of isolates, the combination with AVI did not improve its activity. LCB10-0200/AVI was active against CTX-M-, SHV-, CMY-, and KPC- producing E. coli and K. pneumoniae, while LCB10-0200 alone was active against ADC-, OXA-, and VIM- producing A. baumannii and P. aeruginosa. Both LCB10-0200 and LCB10-0200/AVI displayed low activity against IMP- and NDM- producing strains. LCB10-0200 alone exhibited strong activity against selected strains. The addition of AVI significantly increased LCB10-0200 activity against carbapenem-resistant E. coli, K. pneumoniae.
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Affiliation(s)
- Le Phuong Nguyen
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul 03722, Korea
| | - Chul Soon Park
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
| | - Naina Adren Pinto
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul 03722, Korea
| | - Hyunsook Lee
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul 03722, Korea
| | - Hyun Soo Seo
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
| | - Thao Nguyen Vu
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul 03722, Korea
| | - Hung Mai
- School of Engineering and Applied Science, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - An H. T. Pham
- UCI School of Biological Sciences, University of California, Irvine, CA 92617, USA;
| | - Eris Jang
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
| | | | | | - Kevin Nguyen
- J. Craig Venter Institute, Rockville, MD 20850, USA; (K.N.); (R.W.); (R.D.); (D.E.F.)
| | - Richard White
- J. Craig Venter Institute, Rockville, MD 20850, USA; (K.N.); (R.W.); (R.D.); (D.E.F.)
| | - Roshan D’Souza
- J. Craig Venter Institute, Rockville, MD 20850, USA; (K.N.); (R.W.); (R.D.); (D.E.F.)
| | - Derrick E. Fouts
- J. Craig Venter Institute, Rockville, MD 20850, USA; (K.N.); (R.W.); (R.D.); (D.E.F.)
| | - Dongeun Yong
- Department of Laboratory Medicine and Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Korea; (L.P.N.); (C.S.P.); (N.A.P.); (H.L.); (H.S.S.); (T.N.V.); (E.J.)
- Brain Korea 21 PLUS Project for Medical Science, Yonsei University, Seoul 03722, Korea
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Mushtaq S, Garello P, Vickers A, Woodford N, Livermore DM. Cefepime/tazobactam compared with other tazobactam combinations against problem Gram-negative bacteria. Int J Antimicrob Agents 2021; 57:106318. [PMID: 33716176 DOI: 10.1016/j.ijantimicag.2021.106318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/10/2021] [Accepted: 03/06/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Piperacillin/tazobactam has long been a broad-spectrum 'workhorse' antibiotic; however, it is compromised by resistance. One response is to re-partner tazobactam with cefepime, which is easier to protect, being less β-lactamase labile, and to use a high-dose and prolonged infusion. On this basis, Wockhardt are developing cefepime/tazobactam (WCK 4282) as a 2+2 g q8h combination with a 90-min infusion. METHODS The activity of cc cefepime/tazobactam was assessed, with other tazobactam combinations as comparators, against 1632 Enterobacterales, 745 Pseudomonas aeruginosa and 450 other non-fermenters, as submitted to the UK National Reference Laboratory. These were categorised by carbapenemase-gene detection and interpretive reading of phenotypes, with MICs determined by British Society for Antimicrobial Chemotherapy agar dilution. RESULTS Although higher breakpoints may be justifiable, based on the pharmacodynamics, the results were reviewed against current cefepime criteria. On this basis, cefepime/tazobactam was broadly active against Enterobacterales with AmpC enzymes and extended-spectrum β-lactamases (ESBLs), even when they had ertapenem resistance, suggesting porin loss. At 8+8 mg/L, activity extended to > 90% of Enterobacterales with OXA-48 and KPC carbapenemases, although the MICs for KPC producers belonging to the international Klebsiella pneumoniae ST258 lineage were higher; metallo-β-lactamase producers remained resistant. Cefepime/tazobactam was less active than ceftolozane/tazobactam against Pseudomonas aeruginosa with AmpC de-repression or high-level efflux but achieved wider antipseudomonal coverage than piperacillin/tazobactam. Activity against other non-fermenters was species-specific. CONCLUSION Overall, cefepime/tazobactam had a spectrum exceeding those of piperacillin/tazobactam and ceftolozane/tazobactam and resembling or exceeding that of carbapenems. Used as a 'new-combination of old-agents' it has genuine potential to be 'carbapenem-sparing'.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Paolo Garello
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK
| | - David M Livermore
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, UK; Norwich Medical School, University of East Anglia, Norwich, UK.
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Edelstein MV, Skleenova EY, Trushin IV, Kuzmenkov AY, Martinovich AА, Shek EA, Shajdullina ER, Avramenko AA, Vinogradova AG, Ivanchik NV, Sukhorukova MV, Romanov AV, Mikotina AV, Azyzov IS, Dekhnich AV, Kozlov RS. Susceptibility of clinical Enterobacterales and Pseudomonas aeruginosa isolates to ceftazidimeavibactam in Russia: multicenter local laboratory databased surveillance. CLINICAL MICROBIOLOGY AND ANTIMICROBIAL CHEMOTHERAPY 2021. [DOI: 10.36488/cmac.2021.3.264-278] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Objective.
To assess the in vitro activity of ceftazidime-avibactam against clinical Enterobacterales and Pseudomonas aeruginosa isolates in various regions of Russia based on results of local susceptibility testing by disk diffusion method.
Materials and Methods.
Overall, 160 laboratories located in 61 Russian cities participated in this surveillance during 2018-2020. All consecutive clinical isolates of Enterobacterales and Pseudomonas aeruginosa in each participating laboratory were included in the study. Ceftazidime-avibactam susceptibility testing was done by disc-diffusion method in accordance with current EUCAST recommendations. Susceptibility data for carbapenems and III-IV generation cephalosporins, as well as results of carbapenemases detection, were also reported, if available. All the data were recorded in electronic case report form developed on the OpenClinica online platform (www.openclinica.com). Data analysis and reporting were done using AMRcloud online platform (https://amrcloud.net/).
Results.
In total, we received information on antimicrobial susceptibility of 22,121 isolates, including 17,456 (78.9%) Enterobacterales and 4,665 (21.1%) P. aeruginosa. Less than 9% of Enterobacterales isolates were resistant to ceftazidime-avibactam. At the same time rates of resistance to ceftazidime, cefotaxime, cefepime, ertapenem, imipenem, and meropenem were 54.1%, 58.9%, 59.4%, 41.4%, 23.9%, and 21.3%. Among Enterobacterales the highest level of resistance to ceftazidime-avibactam was detected in K. pneumoniae (16.5%), lowest – in E. coli (2.1%). Some increase of resistance to ceftazidimeavibactam was noted during the study – from 7.8% in 2018-2019 to 9.6% in 2020 (p = 0.0001). Rate of resistance to ceftazidime-avibactam in P. aeruginosa was 33.1%. At the same time rates of resistance to ceftazidime, cefepime, imipenem, and meropenem were 51.1%, 54.5%, 50%, and 47.3%. During the study there was statistically significant decrease in resistance to ceftazidime-avibactam in P. aeruginosa (p = 0.0001). Resistance rates for all beta-lactams for both Enterobacterales and P. aeruginosa were higher in nosocomial isolates than in community-acquired isolates.
Conclusions.
Ceftazidime-avibactam demonstrated significantly higher in vitro activity against Enterobacterales and P. aeruginosa Russian clinical isolates comparing with commonly used carbapenems and extended spectrum cephalosporins. Access for all study data available at the AMRcloud online platform (https://amrcloud.net/ru/project/cazavi-1-2/).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Ilya S. Azyzov
- Institute of Antimicrobial Chemotherapy (Smolensk, Russia)
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Yahav D, Giske CG, Grāmatniece A, Abodakpi H, Tam VH, Leibovici L. New β-Lactam-β-Lactamase Inhibitor Combinations. Clin Microbiol Rev 2020; 34:e00115-20. [PMID: 33177185 PMCID: PMC7667665 DOI: 10.1128/cmr.00115-20] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The limited armamentarium against drug-resistant Gram-negative bacilli has led to the development of several novel β-lactam-β-lactamase inhibitor combinations (BLBLIs). In this review, we summarize their spectrum of in vitro activities, mechanisms of resistance, and pharmacokinetic-pharmacodynamic (PK-PD) characteristics. A summary of available clinical data is provided per drug. Four approved BLBLIs are discussed in detail. All are options for treating multidrug-resistant (MDR) Enterobacterales and Pseudomonas aeruginosa Ceftazidime-avibactam is a potential drug for treating Enterobacterales producing extended-spectrum β-lactamase (ESBL), Klebsiella pneumoniae carbapenemase (KPC), AmpC, and some class D β-lactamases (OXA-48) in addition to carbapenem-resistant Pseudomonas aeruginosa Ceftolozane-tazobactam is a treatment option mainly for carbapenem-resistant P. aeruginosa (non-carbapenemase producing), with some activity against ESBL-producing Enterobacterales Meropenem-vaborbactam has emerged as treatment option for Enterobacterales producing ESBL, KPC, or AmpC, with similar activity as meropenem against P. aeruginosa Imipenem-relebactam has documented activity against Enterobacterales producing ESBL, KPC, and AmpC, with the combination having some additional activity against P. aeruginosa relative to imipenem. None of these drugs present in vitro activity against Enterobacterales or P. aeruginosa producing metallo-β-lactamase (MBL) or against carbapenemase-producing Acinetobacter baumannii Clinical data regarding the use of these drugs to treat MDR bacteria are limited and rely mostly on nonrandomized studies. An overview on eight BLBLIs in development is also provided. These drugs provide various levels of in vitro coverage of carbapenem-resistant Enterobacterales, with several drugs presenting in vitro activity against MBLs (cefepime-zidebactam, aztreonam-avibactam, meropenem-nacubactam, and cefepime-taniborbactam). Among these drugs, some also present in vitro activity against carbapenem-resistant P. aeruginosa (cefepime-zidebactam and cefepime-taniborbactam) and A. baumannii (cefepime-zidebactam and sulbactam-durlobactam).
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Affiliation(s)
- Dafna Yahav
- Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Christian G Giske
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Alise Grāmatniece
- Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
- Pauls Stradins University Hospital, University of Latvia, Riga, Latvia
| | - Henrietta Abodakpi
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Vincent H Tam
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, Texas, USA
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tikva, Israel
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New Carbapenemase Inhibitors: Clearing the Way for the β-Lactams. Int J Mol Sci 2020; 21:ijms21239308. [PMID: 33291334 PMCID: PMC7731173 DOI: 10.3390/ijms21239308] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 01/13/2023] Open
Abstract
Carbapenem resistance is a major global health problem that seriously compromises the treatment of infections caused by nosocomial pathogens. Resistance to carbapenems mainly occurs via the production of carbapenemases, such as VIM, IMP, NDM, KPC and OXA, among others. Preclinical and clinical trials are currently underway to test a new generation of promising inhibitors, together with the recently approved avibactam, relebactam and vaborbactam. This review summarizes the main, most promising carbapenemase inhibitors synthesized to date, as well as their spectrum of activity and current stage of development. We particularly focus on β-lactam/β-lactamase inhibitor combinations that could potentially be used to treat infections caused by carbapenemase-producer pathogens of critical priority. The emergence of these new combinations represents a step forward in the fight against antimicrobial resistance, especially in regard to metallo-β-lactamases and carbapenem-hydrolysing class D β-lactamases, not currently inhibited by any clinically approved inhibitor.
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Mushtaq S, Sadouki Z, Vickers A, Livermore DM, Woodford N. In Vitro Activity of Cefiderocol, a Siderophore Cephalosporin, against Multidrug-Resistant Gram-Negative Bacteria. Antimicrob Agents Chemother 2020; 64:e01582-20. [PMID: 32958717 PMCID: PMC7674041 DOI: 10.1128/aac.01582-20] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 09/02/2020] [Indexed: 02/06/2023] Open
Abstract
Cefiderocol is a parenteral siderophore cephalosporin with a catechol-containing 3' substituent. We evaluated its MICs against Gram-negative bacteria, using iron-depleted Mueller-Hinton broth. The panel comprised 305 isolates of Enterobacterales, 111 of Pseudomonas aeruginosa, and 99 of Acinetobacter baumannii, all selected for carbapenem resistance and multidrug resistance to other agents. At 2 and 4 μg/ml, cefiderocol inhibited 78.7 and 92.1%, respectively, of all Enterobacterales isolates tested, with rates of 80 to 100% for isolates with all modes of carbapenem resistance except NDM enzymes (41.0% inhibited at 2 μg/ml and 72.1% at 4 μg/ml) or combinations of extended-spectrum β-lactamase (ESBL) and porin loss (61.5% inhibited at 2 μg/ml and 88.5% at 4 μg/ml). Cefiderocol also inhibited 81.1 and 86.5% of all P. aeruginosa isolates at 2 and 4 μg/ml, respectively, with rates of 80 to 100% for isolates with VIM, IMP, GES, or VEB β-lactamases and slightly lower rates for those with NDM (45.5% at 2 μg/ml and 72.7% at 4 μg/ml) and PER (66.7% at 2 μg/ml and 73.3% at 4 μg/ml) enzymes; 63.3% of P. aeruginosa isolates were inhibited at the FDA's 1-μg/ml breakpoint. Lastly, cefiderocol at 2 and 4 μg/ml inhibited 80.8 and 88.9% of the A. baumannii isolates, respectively, with rates of >85% for isolates with OXA-51-like, -23, -24, or -58 enzymes and 50% at 2 μg/ml and 80% at 4 μg/ml for those with NDM carbapenemases. Dipicolinic acid and avibactam weakly potentiated cefiderocol against Enterobacterales isolates with metallo-β-lactamases (MBLs) and serine carbapenemase, respectively, indicating incomplete β-lactamase stability.
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Affiliation(s)
- Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Zahra Sadouki
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
| | - Anna Vickers
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
| | - David M Livermore
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, National Infection Service, Public Health England, London, United Kingdom
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Ortiz de la Rosa JM, Nordmann P, Poirel L. ESBLs and resistance to ceftazidime/avibactam and ceftolozane/tazobactam combinations in Escherichia coli and Pseudomonas aeruginosa. J Antimicrob Chemother 2020; 74:1934-1939. [PMID: 31225611 DOI: 10.1093/jac/dkz149] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 02/27/2019] [Accepted: 03/15/2019] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVES To evaluate the efficacy of the recently launched β-lactam/β-lactamase inhibitor combinations ceftazidime/avibactam and ceftolozane/tazobactam against ESBL-producing Escherichia coli and Pseudomonas aeruginosa strains. METHODS A series of ESBL-encoding genes (blaTEM, blaSHV, blaCTX-M, blaVEB, blaPER, blaGES and blaBEL) was cloned and expressed in E. coli or P. aeruginosa recipient strains. Cultures of E. coli TOP10 harbouring recombinant plasmids and therefore producing the different ESBLs tested were grown in order to perform measurements of catalytic activities, using benzylpenicillin, ceftazidime and ceftolozane as substrates. IC50s were additionally determined for clavulanic acid, tazobactam and avibactam. RESULTS We showed here an overall better activity of ceftazidime/avibactam compared with ceftolozane/tazobactam toward ESBL-producing E. coli and P. aeruginosa. Several ESBLs of the GES, PER and BEL types conferred resistance to ceftolozane/tazobactam in E. coli and P. aeruginosa. For GES-6 and PER-1 producers, resistance to ceftolozane/tazobactam could be explained by a high hydrolysis of ceftolozane and a low activity of tazobactam as an inhibitor. On the other hand, PER-producing P. aeruginosa also exhibited resistance to ceftazidime/avibactam. CONCLUSIONS Altogether, the results show that the ESBL PER-1, which is widespread worldwide, may be a source of resistance to both ceftolozane/tazobactam and ceftazidime/avibactam. Excellent activity of ceftazidime/avibactam was highlighted for both ESBL-producing E. coli and ESBL-producing P. aeruginosa.
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Affiliation(s)
- José-Manuel Ortiz de la Rosa
- Emerging Antibiotic Resistance Unit, Medical and Molecular Microbiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland
| | - Patrice Nordmann
- Emerging Antibiotic Resistance Unit, Medical and Molecular Microbiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland.,Swiss National Reference Centre for Emerging Antibiotic Resistance, Fribourg, Switzerland.,INSERM European Unit (LEA), IAME, Paris, France.,University of Lausanne and University Hospital Centre, Lausanne, Switzerland
| | - Laurent Poirel
- Emerging Antibiotic Resistance Unit, Medical and Molecular Microbiology, Department of Medicine, University of Fribourg, Fribourg, Switzerland.,Swiss National Reference Centre for Emerging Antibiotic Resistance, Fribourg, Switzerland.,INSERM European Unit (LEA), IAME, Paris, France
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Rubic Z, Soprek S, Jelic M, Novak A, Goic-Barisic I, Radic M, Tambic-Andrasevic A, Tonkic M. Molecular Characterization of β-Lactam Resistance and Antimicrobial Susceptibility to Possible Therapeutic Options of AmpC-Producing Multidrug-Resistant Proteus mirabilis in a University Hospital of Split, Croatia. Microb Drug Resist 2020; 27:162-169. [PMID: 32429775 DOI: 10.1089/mdr.2020.0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This study was performed to elucidate genetic relatedness and molecular resistance mechanisms of AmpC-producing multidrug-resistant Proteus mirabilis isolates in University Hospital of Split (UHS), and define efficient antibiotics in vitro. A total of 100 nonrepeated, consecutive, amoxicillin/clavulanate- and cefoxitin-resistant P. mirabilis isolates were collected, mostly from urine (44%) and skin and soft-tissue samples (30%). They were all positive in cefoxitin Hodge test and negative for extended spectrum beta-lactamase production. Pulsed field gel electrophoresis identified four clusters and two singletons, with 79% of isolates in dominant cluster. Molecular characterization and I-CeuI analysis of representatives revealed blaCMY-16 gene located on chromosome, and insertion element ISEcp1 positioned 110 pb upstream of blaCMY-16 starting codon. They also harbored blaTEM-1, except one with blaTEM-2. They were all resistant to trimethoprim-sulfamethoxazole, all but one to quinolones, and 81% to all aminoglycosides, while 77% were susceptible (S) and 22% intermediate (I) to piperacillin/tazobactam, and 4% were S and 68% I to cefepime. Only 15% were S to ceftolozane/tazobactam. Meropenem, ertapenem, ceftazidime/avibactam, temocillin, and fosfomycin were 100% efficient in vitro. This is the first report of blaCMY-16 gene in P. mirabilis from hospital samples in Croatia. The findings are in accordance with Italian and Greek reports. The clonal nature of outbreak suggests the high potential of clonal spread. Alternative agents should be considered to spare carbapenem usage.
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Affiliation(s)
- Zana Rubic
- Department of Clinical Microbiology, University Hospital of Split, Split, Croatia.,University of Split School of Medicine, Split, Croatia
| | - Silvija Soprek
- Department of Clinical Microbiology, University Hospital for Infectious Diseases "Dr. Fran Mihaljevic," Zagreb, Croatia
| | - Marko Jelic
- Department of Clinical Microbiology, University Hospital for Infectious Diseases "Dr. Fran Mihaljevic," Zagreb, Croatia
| | - Anita Novak
- Department of Clinical Microbiology, University Hospital of Split, Split, Croatia.,University of Split School of Medicine, Split, Croatia
| | - Ivana Goic-Barisic
- Department of Clinical Microbiology, University Hospital of Split, Split, Croatia.,University of Split School of Medicine, Split, Croatia
| | - Marina Radic
- Department of Clinical Microbiology, University Hospital of Split, Split, Croatia.,University of Split School of Medicine, Split, Croatia
| | - Arjana Tambic-Andrasevic
- Department of Clinical Microbiology, University Hospital for Infectious Diseases "Dr. Fran Mihaljevic," Zagreb, Croatia.,University of Zagreb School of Dental Medicine, Zagreb, Croatia
| | - Marija Tonkic
- Department of Clinical Microbiology, University Hospital of Split, Split, Croatia.,University of Split School of Medicine, Split, Croatia
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Comparison of Treatment Outcomes between Analysis Populations in the RESTORE-IMI 1 Phase 3 Trial of Imipenem-Cilastatin-Relebactam versus Colistin plus Imipenem-Cilastatin in Patients with Imipenem-Nonsusceptible Bacterial Infections. Antimicrob Agents Chemother 2020; 64:AAC.02203-19. [PMID: 32094127 DOI: 10.1128/aac.02203-19] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 02/13/2020] [Indexed: 02/07/2023] Open
Abstract
The RESTORE-IMI 1 phase 3 trial demonstrated the efficacy and safety of imipenem-cilastatin (IMI) combined with relebactam (REL) for treating imipenem-nonsusceptible infections. The objective of this analysis was to compare the outcomes among patients meeting eligibility requirements based on central laboratory susceptibility versus local laboratory susceptibility. Patients with serious infections caused by imipenem-nonsusceptible, colistin-susceptible, and imipenem-REL-susceptible pathogens were randomized 2:1 to IMI-REL plus placebo or colistin plus IMI for 5 to 21 days. The primary endpoint was a favorable overall response. Key endpoints included the clinical response and all-cause mortality. We compared outcomes between the primary microbiological modified intent-to-treat (mMITT) population, where eligibility was based on central laboratory susceptibility testing, and the supplemental mMITT (SmMITT) population, where eligibility was based on local, site-level testing. The SmMITT (n = 41) and MITT (n = 31) populations had similar baseline characteristics, including sex, age, illness severity, and renal function. In both analysis populations, favorable overall response rates in the IMI-REL treatment group were >70%. Favorable clinical response rates at day 28 were 71.4% for IMI-REL and 40.0% for colistin plus IMI in the mMITT population, whereas they were 75.0% for IMI-REL and 53.8% for colistin plus IMI in the SmMITT population. Day 28 all-cause mortality rates were 9.5% for IMI-REL and 30.0% for colistin plus IMI in the mMITT population, whereas they were 10.7% for IMI-REL and 23.1% for colistin plus IMI in the SmMITT population. The outcomes in the SmMITT population were generally consistent with those in the mMITT population, suggesting that outcomes may be applicable to the real-world use of IMI-REL for treating infections caused by imipenem-nonsusceptible Gram-negative pathogens. (This study has been registered at ClinicalTrials.gov under identifier NCT02452047.).
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Meropenem-Vaborbactam versus Ceftazidime-Avibactam for Treatment of Carbapenem-Resistant Enterobacteriaceae Infections. Antimicrob Agents Chemother 2020; 64:AAC.02313-19. [PMID: 32094128 DOI: 10.1128/aac.02313-19] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/13/2020] [Indexed: 12/21/2022] Open
Abstract
The comparative efficacy of ceftazidime-avibactam and meropenem-vaborbactam for treatment of carbapenem-resistant Enterobacteriaceae (CRE) infections remains unknown. This was a multicenter, retrospective cohort study of adults with CRE infections who received ceftazidime-avibactam or meropenem-vaborbactam for ≥72 hours from February 2015 to October 2018. Patients with a localized urinary tract infection and repeat study drug exposures after the first episode were excluded. The primary endpoint was clinical success compared between treatment groups. Secondary endpoints included 30- and 90-day mortality, adverse events (AE), 90-day CRE infection recurrence, and development of resistance in patients with recurrent infection. A post hoc subgroup analysis was completed comparing patients who received ceftazidime-avibactam monotherapy, ceftazidime-avibactam combination therapy, and meropenem-vaborbactam monotherapy. A total of 131 patients were included (ceftazidime-avibactam, n = 105; meropenem-vaborbactam, n = 26), 40% of whom had bacteremia. No significant difference in clinical success was observed between groups (62% versus 69%; P = 0.49). Patients in the ceftazidime-avibactam arm received combination therapy more often than patients in the meropenem-vaborbactam arm (61% versus 15%; P < 0.01). No difference in 30- and 90-day mortality resulted, and rates of AE were similar between groups. In patients with recurrent infection, development of resistance occurred in three patients that received ceftazidime-avibactam monotherapy and in no patients in the meropenem-vaborbactam arm. Clinical success was similar between patients receiving ceftazidime-avibactam and meropenem-vaborbactam for treatment of CRE infections, despite ceftazidime-avibactam being used more often as a combination therapy. Development of resistance was more common with ceftazidime-avibactam monotherapy.
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Palwe S, Khobragade K, Kharat AS. Preserving the Dwindling β-lactams-Based Empiric Therapy Options for Gram-Negative Infections in Challenging Resistance Scenario: Lessons Learned and Way Forward. Microb Drug Resist 2019; 26:637-651. [PMID: 31851576 DOI: 10.1089/mdr.2019.0195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Appropriate empiric therapy reduces mortality and morbidity associated with serious Gram-negative infections. β-lactams (BLs) owing to their safety, efficacy, and coverage spectrum are the most preferred agents for empiric use. Inappropriate use of older penicillins and cephalosporins led to selection and spread of resistant clones. As a result, these valuable agents have lost their reliability compelling clinicians to often use erstwhile last-line therapies such as carbapenems. Excessive carbapenems use imposed collateral damage by selecting difficult-to-treat carbapenem-resistant organisms. Lack of empiric therapeutic options amenable for use in infections caused by contemporary pathogens was realized by the pharmaceutical industry leading to intensive efforts in discovering novel antibiotics. These efforts led to the approval of newer β-lactams and β-lactamase inhibitor (BL-BLI) combination. This review elaborates the past trends in empirical use of BLs and ensuing patterns of resistance emergence in Gram-negatives. Furthermore, a critical appraisal of newer BL-BLIs has been presented to identify the appropriate clinical situations for their use to ensure clinical efficacy coupled with minimal resistance selection. These learning have been derived from past trends of clinical usage of older empiric therapies so that the therapeutic utility of newer agents is preserved for long in light of dwindling global antibiotics pipeline.
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Affiliation(s)
- Snehal Palwe
- Department of Environmental Science, SB College of Science, Aurangabad, India
| | - Kshama Khobragade
- Department of Environmental Science, SB College of Science, Aurangabad, India
| | - Arun S Kharat
- Laboratory of Microbiology, Jawaharlal Nehru University, New Delhi, India
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Li J, Li C, Cai X, Shi J, Feng L, Tang K, Tong Y, Li Y. Performance of modified carbapenem inactivation method and inhibitor-based combined disk test in the detection and distinguishing of carbapenemase producing Enterobacteriaceae. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:566. [PMID: 31807547 DOI: 10.21037/atm.2019.09.43] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background This study aimed to evaluate the performance of modified carbapenem inactivation method (mCIM) combined EDTA-carbapenem inactivation method (eCIM), and inhibitor-based combined disk test (CDT) in the detection and distinguishing of carbapenemase production in Enterobacteriaceae. Methods A total of 101 nonrepetitive carbapenem insensitive Enterobacteriaceae [minimal inhibitory concentration (MIC) ≥2 µg/mL] were tested by mCIM, eCIM and CDT respectively, and the major carbapenemase genes including blaKPC, blaNDM, blaIMP, blaVIM and blaOXA-48-like genes were detected by polymerase chain reaction (PCR) as control. Results Seventy-nine (78.2%) of isolates were found to harbour one or more carbapenemase genes by PCR, with blaKPC and blaNDM being the most common genes. OXA-48-like genes were undetectable. The coincidence rate of mCIM combined eCIM and CDT was 97.5% (77/79) and 96.2% (76/79) respectively, compared with gene detection. Both assays had a misclassification in two blaKPC+NDM-producing isolates of Klebsiella oxytoca. The sensitivity and specificity of two assays above were 100.0% vs. 95.0% and 98.4% vs. 98.4%, respectively in distinguishing serine-carbapenemase, while they were 95.1% vs. 97.6% and 100% vs. 100.0%, respectively in distinguishing metallo-carbapenemase. Conclusions mCIM combined eCIM and the CDT are both useful tools for the reliable detection and distinguishing single serine-carbapenemase or metallo-carbapenemase, but not for mixed types.
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Affiliation(s)
- Juan Li
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Congrong Li
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Xuan Cai
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Jinling Shi
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Lina Feng
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Kewen Tang
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yongqing Tong
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
| | - Yan Li
- Department of Clinical Laboratory, Renmin Hospital of Wuhan University, Wuhan 430060, China
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Livermore DM, Mushtaq S, Doumith M, Jamrozy D, Nichols WW, Woodford N. Selection of mutants with resistance or diminished susceptibility to ceftazidime/avibactam from ESBL- and AmpC-producing Enterobacteriaceae. J Antimicrob Chemother 2019; 73:3336-3345. [PMID: 30247546 DOI: 10.1093/jac/dky363] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/13/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction Difficult Gram-negative infections are increasingly treated with new β-lactamase inhibitor combinations, e.g. ceftazidime/avibactam. Disturbingly, mutations in KPC carbapenemases can confer ceftazidime/avibactam resistance, which is sometimes selected during therapy. We explored whether this risk extended to AmpC and ESBL enzymes. Methods Mutants were selected by plating AmpC-derepressed strains, ESBL producers and ceftazidime-susceptible controls on agar containing ceftazidime + avibactam (1 or 4 mg/L). MICs were determined by CLSI agar dilution; WGS was by Illumina methodology. Results Using 2× MIC of ceftazidime + 1 mg/L avibactam, mutants were selected from all strain types at frequencies of 10-7-10-9. Rates diminished to <10-9 with 4 mg/L avibactam or higher MIC multiples, except with AmpC-derepressed Enterobacteriaceae. Characterized mutants (n = 10; MICs 4-64 mg/L) of AmpC-derepressed strains had modifications in ampC, variously giving Arg168Pro/His, Gly176Arg/Asp, Asn366Tyr or small deletions around positions 309-314. Mutants of ESBL producers (n = 19; MICs 0.5-16 mg/L) mostly had changes affecting permeability, efflux or β-lactamase quantity; only one had an altered β-lactamase, with an Asp182Tyr substitution in CTX-M-15, raising the ceftazidime/avibactam MIC, but abrogating other cephalosporin resistance. Mutants of ceftazidime-susceptible strains were not sequenced, but phenotypes suggested altered drug accumulation or, for Enterobacter cloacae only, AmpC derepression. In further experiments, avibactam reduced, but did not abolish, selection of AmpC-derepressed Enterobacteriaceae by ceftazidime. Conclusions Most mutants of AmpC-derepressed Enterobacteriaceae had structural mutations in ampC; those of ESBL producers mostly had genetic modifications outside β-lactamase genes, commonly affecting uptake, efflux, or β-lactamase quantity. The clinical significance of these observations remains to be determined.
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Affiliation(s)
- David M Livermore
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK.,Norwich Medical School, University of East Anglia, Norwich, UK
| | - Shazad Mushtaq
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Michel Doumith
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | - Dorota Jamrozy
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
| | | | - Neil Woodford
- Antimicrobial Resistance and Healthcare Associated Infections (AMRHAI) Reference Unit, National Infection Service, Public Health England, 61 Colindale Avenue, London, UK
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Sternbach N, Leibovici Weissman Y, Avni T, Yahav D. Efficacy and safety of ceftazidime/avibactam: a systematic review and meta-analysis. J Antimicrob Chemother 2019; 73:2021-2029. [PMID: 29659836 DOI: 10.1093/jac/dky124] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 03/12/2018] [Indexed: 12/29/2022] Open
Abstract
Background Ceftazidime/avibactam is approved for complicated intra-abdominal and urinary tract infections (UTIs) based on results from randomized controlled trials (RCTs). Data regarding its effectiveness in treating hospital-acquired infections or resistant pathogens have not been systematically compiled. Methods A systematic review and meta-analysis including RCTs evaluating ceftazidime/avibactam versus comparator for the treatment of any infection. Primary outcome was 30 day all-cause mortality. Subgroups of hospital-acquired infections and specific resistance phenotypes were planned. Results Seven publications (eight trials, 4093 patients) were included, reporting a baseline ∼25% of ESBL-carrying Enterobacteriaceae. No significant difference between ceftazidime/avibactam and comparator (mostly carbapenem) was demonstrated for 30 day all-cause mortality, late follow-up mortality and clinical response [relative risk (RR) 1.10, 95% CI 0.70-1.72, P = 0.69; RR 1.23, 95% CI 0.87-1.76, P = 0.25; RR 0.98, 95% CI 0.96-1.01, P = 0.21, respectively, without significant heterogeneity]. Higher microbiological response rate was demonstrated with ceftazidime/avibactam in patients with UTI (RR 1.14, 1.0-1.29, P = 0.05, I2 = 51%). No significant difference in clinical response was demonstrated for patients with ceftazidime-resistant pathogens (RR 1.02, 95% CI 0.94-1.10, P = 0.66, I2 = 0%). Results for other subgroups of resistant pathogens or hospital-acquired infection were not available. Serious adverse events (SAEs) were significantly more common with ceftazidime/avibactam (RR 1.24, 95% CI 1.00-1.54, P = 0.05, I2 = 0%). Conclusions Ceftazidime/avibactam is clinically and microbiologically as effective as carbapenems for treatment of infections in a setting of ∼25% ESBL-carrying Enterobacteriaceae. Safety of the drug should be further evaluated owing to a higher rate of SAEs compared with carbapenems. Further studies should assess the drug's effectiveness in the treatment of carbapenemase-producing Enterobacteriaceae.
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Affiliation(s)
- Neta Sternbach
- Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Yaara Leibovici Weissman
- Medicine D, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.,Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Tomer Avni
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Sackler School of Medicine, Tel Aviv University, Ramat Aviv, Israel.,Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
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Trinh TD, Smith JR, Rybak MJ. Parenteral Fosfomycin for the Treatment of Multidrug Resistant Bacterial Infections: The Rise of the Epoxide. Pharmacotherapy 2019; 39:1077-1094. [PMID: 31487056 DOI: 10.1002/phar.2326] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Fosfomycin was initially discovered in 1969 but has recently gained renewed interest for the treatment of multidrug-resistant (MDR) bacterial infections, particularly in the United States. Its unique mechanism of action, bactericidal activity, broad spectrum of activity, and relatively safe and tolerable adverse effect profile make it a great addition to the dwindling antibiotic armamentarium. Fosfomycin contains a three-membered epoxide ring with a direct carbon to phosphorous bond that bypasses the intermediate oxygen bond commonly present in other organophosphorous compounds; this structure makes the agent unique from other antibiotics. Despite nearly 50 years of parenteral fosfomycin use in Europe, fosfomycin has retained stable activity against most pathogens. Furthermore, fosfomycin demonstrated in vitro synergy in combination with other cell wall-active antibiotics (e.g., β-lactams, daptomycin). These combinations may offer respite for severe infections due to MDR gram-positive and gram-negative bacteria. The intravenous (IV) formulation is currently under review in the United States, and apropos, this review collates more contemporary evidence (i.e., studies published between 2000 and early 2019) in anticipation of this development. The approval of IV fosfomycin provides another option for consideration in the management of MDR infections. Its unique structure will give rise to a promising epoxide epoch in the battle against MDR bacteria.
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Affiliation(s)
- Trang D Trinh
- Medication Outcomes Center, Department of Clinical Pharmacy, School of Pharmacy, University of California, San Francisco, San Francisco, California
| | - Jordan R Smith
- Department of Clinical Sciences, Fred Wilson School of Pharmacy, High Point University, High Point, North Carolina
| | - Michael J Rybak
- Anti-Infective Research Laboratory, Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
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Livermore DM. The 2018 Garrod Lecture: Preparing for the Black Swans of resistance. J Antimicrob Chemother 2019; 73:2907-2915. [PMID: 30351434 DOI: 10.1093/jac/dky265] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
The need for governments to encourage antibiotic development is widely agreed, with 'market entry rewards' being suggested. Unless these are to be spread widely-which is unlikely given the $1 billion sums proposed-we should be wary, for this approach is likely to evolve into one of picking, or commissioning, a few 'winners' based on extrapolation of current resistance trends. The hazard to this is that whilst the evolution of resistance has predictable components, notably mutation, it also has completely unpredictable ones, contingent upon 'Black Swan' events. These include the escape of 'new' resistance genes from environmental bacteria and the recruitment of these genes by promiscuous mobile elements and epidemic strains. Such events can change the resistance landscape rapidly and unexpectedly, as with the rise of Escherichia coli ST131 with CTX-M ESBLs and the emergence of 'impossible' VRE. Given such unpredictability, we simply cannot say with any certainty, for example, which of the four current approaches to combating MBLs offers the best prospect of sustainable prizeworthy success. Only time will tell, though it is encouraging that multiple potential approaches to overcoming these problematic enzymes are being pursued. Rather than seeking to pick winners, governments should aim to reduce development barriers, as with recent relaxation of trial regulations. In particular, once β-lactamase inhibitors have been successfully trialled with one partner drug, there is scope to facilitate licensing them for partnering with other established β-lactams, thereby insuring against new emerging resistance.
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Affiliation(s)
- David M Livermore
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
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Horcajada JP, Montero M, Oliver A, Sorlí L, Luque S, Gómez-Zorrilla S, Benito N, Grau S. Epidemiology and Treatment of Multidrug-Resistant and Extensively Drug-Resistant Pseudomonas aeruginosa Infections. Clin Microbiol Rev 2019; 32:32/4/e00031-19. [PMID: 31462403 PMCID: PMC6730496 DOI: 10.1128/cmr.00031-19] [Citation(s) in RCA: 439] [Impact Index Per Article: 87.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
In recent years, the worldwide spread of the so-called high-risk clones of multidrug-resistant or extensively drug-resistant (MDR/XDR) Pseudomonas aeruginosa has become a public health threat. This article reviews their mechanisms of resistance, epidemiology, and clinical impact and current and upcoming therapeutic options. In vitro and in vivo treatment studies and pharmacokinetic and pharmacodynamic (PK/PD) models are discussed. Polymyxins are reviewed as an important therapeutic option, outlining dosage, pharmacokinetics and pharmacodynamics, and their clinical efficacy against MDR/XDR P. aeruginosa infections. Their narrow therapeutic window and potential for combination therapy are also discussed. Other "old" antimicrobials, such as certain β-lactams, aminoglycosides, and fosfomycin, are reviewed here. New antipseudomonals, as well as those in the pipeline, are also reviewed. Ceftolozane-tazobactam has clinical activity against a significant percentage of MDR/XDR P. aeruginosa strains, and its microbiological and clinical data, as well as recommendations for improving its use against these bacteria, are described, as are those for ceftazidime-avibactam, which has better activity against MDR/XDR P. aeruginosa, especially strains with certain specific mechanisms of resistance. A section is devoted to reviewing upcoming active drugs such as imipenem-relebactam, cefepime-zidebactam, cefiderocol, and murepavadin. Finally, other therapeutic strategies, such as use of vaccines, antibodies, bacteriocins, anti-quorum sensing, and bacteriophages, are described as future options.
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Affiliation(s)
- Juan P Horcajada
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Milagro Montero
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Antonio Oliver
- Service of Microbiology, Hospital Son Espases, Instituto de Investigación Sanitaria Illes Balears (IdISBa), Palma de Mallorca, Spain
| | - Luisa Sorlí
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Sònia Luque
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Gómez-Zorrilla
- Service of Infectious Diseases, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Pompeu Fabra, Barcelona, Spain
- Spanish Network for Research in Infectious Diseases (REIPI), Madrid, Spain
| | - Natividad Benito
- Infectious Diseases Unit, Hospital de la Santa Creu i Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Santiago Grau
- Service of Pharmacy, Hospital del Mar, Infectious Pathology and Antimicrobials Research Group, Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Universitat Autònoma de Barcelona, Barcelona, Spain
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Göttig S, Frank D, Mungo E, Nolte A, Hogardt M, Besier S, Wichelhaus TA. Emergence of ceftazidime/avibactam resistance in KPC-3-producing Klebsiella pneumoniae in vivo. J Antimicrob Chemother 2019; 74:3211-3216. [DOI: 10.1093/jac/dkz330] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/14/2019] [Accepted: 07/03/2019] [Indexed: 12/16/2022] Open
Abstract
Abstract
Objectives
The β-lactam/β-lactamase inhibitor combination ceftazidime/avibactam is active against KPC-producing Enterobacterales. Herein, we present molecular and phenotypic characterization of ceftazidime/avibactam resistance in KPC-3-producing Klebsiella pneumoniae that emerged in vivo and in vitro.
Methods
Sequence analysis of blaKPC-3 was performed from clinical and in vitro-generated ceftazidime/avibactam-resistant K. pneumoniae isolates. Time–kill kinetics and the Galleria mellonella infection model were applied to evaluate the activity of ceftazidime/avibactam and imipenem alone and in combination.
Results
The ceftazidime/avibactam-resistant clinical K. pneumoniae isolate revealed the amino acid change D179Y in KPC-3. Sixteen novel mutational changes in KPC-3 among in vitro-selected ceftazidime/avibactam-resistant isolates were described. Time–kill kinetics showed the emergence of a resistant subpopulation under selection pressure with either imipenem or ceftazidime/avibactam. However, combined selection pressure with imipenem plus ceftazidime/avibactam prevented the development of resistance and resulted in bactericidal activity. Concordantly, the G. mellonella infection model revealed that monotherapy with ceftazidime/avibactam is prone to select for resistance in vivo and that combination therapy with imipenem results in significantly better survival.
Conclusions
Ceftazidime/avibactam is a valuable antibiotic against MDR and carbapenem-resistant Enterobacterales. Based on time–kill kinetics as well as an in vivo infection model we postulate a combination therapy of ceftazidime/avibactam and imipenem as a strategy to prevent the development of ceftazidime/avibactam resistance in KPC-producing Enterobacterales in vivo.
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Affiliation(s)
- Stephan Göttig
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Denia Frank
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Eleonora Mungo
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Anika Nolte
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Michael Hogardt
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Silke Besier
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
| | - Thomas A Wichelhaus
- Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Paul-Ehrlich-Str. 40, Frankfurt am Main, Germany
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Zamudio R, Hijazi K, Joshi C, Aitken E, Oggioni MR, Gould IM. Phylogenetic analysis of resistance to ceftazidime/avibactam, ceftolozane/tazobactam and carbapenems in piperacillin/tazobactam-resistant Pseudomonas aeruginosa from cystic fibrosis patients. Int J Antimicrob Agents 2019; 53:774-780. [PMID: 30831233 DOI: 10.1016/j.ijantimicag.2019.02.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 02/15/2019] [Accepted: 02/26/2019] [Indexed: 01/18/2023]
Abstract
Pseudomonas aeruginosa is one of the most important pathogens in cystic fibrosis. This study was conducted to analyse the genetic basis and phylogenetic profile of resistance to ceftazidime/avibactam, ceftolozane/tazobactam and carbapenems in cystic fibrosis P. aeruginosa isolates. Whole genome sequence analysis was conducted of isolates resistant to piperacillin/tazobactam collected from seven hospitals in Scotland since the introduction of these two cephalosporin/β-lactamase inhibitor combinations. Ceftazidime resistance was primarily related to AmpC induction, as tested by cloxacillin inhibition assays, while high-level ceftazidime resistance not reversed by cloxacillin was associated with amino acid variations in AmpC. Only isolates resistant to both ceftazidime/avibactam and ceftolozane/tazobactam carried AmpD mutations, likely resulting in ampC overexpression. All isolates resistant to ceftazidime/avibactam and/or ceftolozane/tazobactam were resistant to carbapenems and showed inactivating mutations in the chromosomal oprD gene. None of the isolates bore class A, B, D plasmid-encoded carbapenemases. This study showed that mutational resistance emerged in phylogenetically distant lineages, which indicates the mutations occur independently without conferring a selective advantage to any phylogenetic lineage. These findings confirm the strong contribution of mutation-driven evolution to the population structure of P. aeruginosa.
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Affiliation(s)
- Roxana Zamudio
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Karolin Hijazi
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK.
| | - Chaitanya Joshi
- School of Medicine, Medical Sciences & Nutrition, University of Aberdeen, Aberdeen, UK
| | - Emma Aitken
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Marco R Oggioni
- Department of Genetics and Genome Biology, University of Leicester, Leicester, UK
| | - Ian M Gould
- Department of Medical Microbiology, Aberdeen Royal Infirmary, Aberdeen, UK
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